Objective

Closure of the artery during carotid endarterectomy (CEA) can be done with or without a patch, or performed with the eversion technique, while the use of intra-operative shunts is optional. The influence of these techniques on subsequent restenosis is uncertain. Long term carotid restenosis rates and risk of future ipsilateral stroke with these techniques were compared.

Methods

Patients who underwent CEA in the International Carotid Stenting Study were divided into patch angioplasty, primary closure, or eversion endarterectomy. Intra-operative shunt use was reported. Carotid duplex ultrasound was performed at each follow up. Primary outcomes were restenosis of ≥ 50% and ≥ 70%, and ipsilateral stroke after the procedure to the end of follow up.

Results

In total, 790 CEA patients had restenosis data at one and five years. Altogether, 511 (64.7%) had patch angioplasty, 232 (29.4%) primary closure, and 47 (5.9%) eversion endarterectomy. The cumulative incidence of ≥ 50% restenosis at one year was 18.9%, 26.1%, and 17.7%, respectively, and at five years it was 25.9%, 37.2%, and 30.0%, respectively. There was no difference in risk between the eversion and patch angioplasty group (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.45 – 1.81; p = .77). Primary closure had a higher risk of restenosis than patch angioplasty (HR 1.45, 95% CI 1.06 – 1.98; p = .019). The cumulative incidence of ≥ 70% restenosis did not differ between primary closure and patch angioplasty (12.1% vs. 7.1%, HR 1.59, 95% CI 0.88 – 2.89; p = .12) or between patch angioplasty and eversion endarterectomy (4.7%, HR 0.45, 95% CI 0.06 – 3.35; p = .44). There was no effect of shunt use on the cumulative incidence of restenosis. Post-procedural ipsilateral stroke was not more common in either of the surgical techniques or shunt use.

Conclusion

Restenosis was more common after primary closure than conventionally with a patch closure. Shunt use had no effect on restenosis. Patch closure is the treatment of choice to avoid restenosis.

中文翻译：

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颈动脉内膜切除术后长期再狭窄率：三种手术技术和术中分流使用的比较

 客观的

颈动脉内膜切除术 (CEA) 期间的动脉闭合可以使用或不使用补片进行，也可以使用外翻技术进行，而术中分流的使用是可选的。这些技术对随后再狭窄的影响尚不确定。比较了使用这些技术的长期颈动脉再狭窄率和未来同侧卒中的风险。

 方法

在国际颈动脉支架研究中接受 CEA 的患者分为补片血管成形术、一期闭合术或外翻动脉内膜切除术。据报告术中使用分流器。每次随访时均进行颈动脉超声检查。主要结局是术后至随访结束时再狭窄≥ 50% 和≥ 70%，以及同侧卒中。

 结果

总共有 790 名 CEA 患者有一年和五年的再狭窄数据。总共有 511 例 (64.7%) 进行了补片血管成形术，232 例 (29.4%) 进行了初次闭合，47 例 (5.9%) 进行了外翻动脉内膜切除术。一年时≥50%再狭窄的累积发生率分别为18.9%、26.1%和17.7%，五年时分别为25.9%、37.2%和30.0%。外翻组和补片血管成形术组之间的风险没有差异（风险比 [HR] 0.90，95% 置信区间 [CI] 0.45 – 1.81； p = .77）。一期闭合术比补片血管成形术有更高的再狭窄风险（HR 1.45，95% CI 1.06 – 1.98； p = .019）。 ≥ 70% 再狭窄的累积发生率在初次闭合和补片血管成形术之间（12.1% vs. 7.1%，HR 1.59，95% CI 0.88 – 2.89； p = .12）或补片血管成形术和外翻动脉内膜切除术之间（4.7%）没有差异。 ，HR 0.45，95% CI 0.06 – 3.35； p = .44）。分流器的使用对再狭窄的累积发生率没有影响。无论是手术技术还是分流术，术后同侧卒中并不常见。

 结论

初次闭合后再狭窄比传统补片闭合更常见。分流术的使用对再狭窄没有影响。补片闭合是避免再狭窄的首选治疗方法。