Comparative Assessment of the Results of Different Techniques of Carotid Bifurcation Reconstruction

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LIST OF ABBREVIATIONS

ACVA ― acute cerebrovascular accident

cCEA ― classic carotid endarterectomy

CF ― cranial nerve

eCEA ― eversion carotid endarterectomy

ICA ― internal carotid artery

PTFE ― polytetrafluorethylene

INTRODUCTION

At present, to restore the patency of the bifurcation of carotid artery in atherosclerotic stenosis, three main reconstruction methods are used.

The first is the open, or classic, carotid endarterectomy (cCEA) introduced in the clinical practice by M. DeBakey (1953), which is now obligatorily performed with stitching a patch in the arteriotomic opening.

The second is prosthetic repair of the internal carotid artery (ICA) first conducted by F. Denman in 1954.

The third method is eversion carotid endarterectomy (eCEA) proposed by a surgical team of Houston Methodist Hospital in 1959. Today, eCEA is used in two variants: the one proposed by R. Kieny (1985) and the second with some modifications by D. Raithel (1987).

If we turn to the data of the authors' teams with significant experience (more than 1,500 observations) of carotid reconstructions, it turns out that the “monosurgical” approach is used somewhat more often (Table 1) [1–6]. Those who use different methods of the interventions on ICA, do not always discuss the indications for choosing a particular method of reconstruction or do not conduct a comparative assessment of their results [7–11]. In small domestic statistical studies devoted to carotid artery reconstructions, indications for a particular method of intervention are not presented either [12–14].

Table 1. Frequency of Using Different Methods of Interventions on Carotid Arteries According to Modern Literature Data

Immediate Results of Different Methods of Carotid Artery Reconstructions

In Table 2, the literature sources are given with comparison of the immediate results of eCEA and cCEA.

Table 2. Comparative Assessment of Immediate Results of Eversion and Classic Carotid Endarterectomy

Note: □ ― no statistically significant differences; ― reliably different results; ACVA ― acute cerebrovascular accident; PTFE ― polytetrafluorethylene

In meta-analysis of C. N. Antonopopulos, et al., comparing results of 8530 eCEA and 7721 cCEA, it was shown that eCEA is associated with a significantly lower frequency of perioperative acute cerebrovascular accidents (ACVA) and deaths from stroke [15]. It is notable that in a later meta-analysis of K. I. Paraskevas, et al., based on the results of already 16,249 eCEA and 33,251 cCEA, it was shown that the above differences exist only in comparison of eCEA and cCEA with the direct suture. But if to compare the eCEA and cCEA data with a patch plasty, the results appear to be identical [16]. R. A. Vinogradov obtained significant differences both in the frequency of strokes after eCEA (0.3%) and cCEA (2.1%), and in ACVA-associated postoperative mortality in these methods of intervention [17].

Analysis of the information of Vascular Quality Initiative Database registry (12,050 eCEA and 83,712 cCEA), did not reveal any differences in the hospital results, unless it was a direct suture (5.1% of cCEA), when 30-day stroke/mortality rate significantly exceeded that in eCEA [18], which coincides with the data of K. I. Paraskevas, et al. [16].

In meta-analysis of A. V. Gavrilenko et al. (2020, 1,718 eCEA and 1,954 cCEA), a statistically significant reduction of the frequency of ACVA in the early postoperative period was found with use of the eversion method [19]. A. N. Kazantsev, et al. (2020) noted the identical frequency of ischemic episodes, mortality and thrombosis with the eversion method and use of a patch [11].

M. K. Lazarides, et al. carried out meta-analysis of 4,400 patients and showed that with use of patches from polytetrafluorethylene (n = 948) or bovine pericardium (n = 249), the immediate results of cCEA are comparable to those after eCEA (n = 431). With use of the direct suture (n = 753), venous (n = 973), dacron (n = 828) or polyurethane patches (n = 258), 30-day stroke or mortality were higher.

In the only work in the literature for comparison of the immediate results of cCEA and ICA prosthetic repair, H. C. Veldenz, et al. did not reveal any differences in the frequency of postoperative ACVA and the endpoint “stroke + mortality from stroke” between 427 cases of cCEA and 51 cases of ICA prosthetic repair (0.7% and 1.9%, 1.2% and 1.9%, respectively) [21].

A comparative evaluation of the immediate results of the three main methods of ICA reconstruction is given only in the work of A. V. Pokrovsky, et al. [22]. The authors studied such results after 630 isolated primary open interventions on the bifurcation of the common carotid artery in atherosclerosis, performed in the vascular surgery department of Vishnevsky Institute of Surgery in the period from January 2008 to December 2010 (Table 3).

Table 3. Comparative Assessment of Immediate Results of Eversion Carotid Endarterectomy and Prosthetic Repair of Internal Carotid Artery [22]

Note: CN ― cranial nerve; eCEA ― eversion carotid endarterectomy; cCEA ― classic carotid endarterectomy; ACVA ― acute cerebrovascular accident

The choice of the method of ICA reconstruction was based on the indications given below.

For eCEA:

- anatomical accessibility of ICA for performing eCEA [23];

- brain tolerance to ICA compression;

- absence of evident calcinosis;

- combination of stenosis and tortuosity of ICA.

For cCEA with obligatory plasty with a patch:

- anatomical inaccessibility of ICA for performing eCEA [23];

- extension of arteriotomy to 5 cm;

- brain intolerance to ICA compression.

For ICA prosthetic repair:

- the length of ICA lesion more than 4–6 cm;

- pronounced calcinosis of the artery.

The following results were obtained (Table 3). The frequency of temporary shunting predictably turned out to be significantly higher with cCEA. The incidence of the cranial nerve (CN) injury did not differ statistically between the groups, ICA thrombosis was significantly more frequent after cCEA and ICA prosthetics. If to turn to such parameters as the frequency of development of homolateral ACVA and the combination of stroke and mortality from stroke, these endpoints significantly differed only in comparison of eCEA and ICA prosthetics. When comparing the results of eCEA and cEEA, as well as of CEA and ICA prosthetics, these parameters were statistically comparable [22].

Long-Term Results of Different Methods of Carotid Reconstructions

In recent years, some comparative, including randomized, studies have been published, concerning remote results of different variants of interventions on the carotid arteries. As in case with the immediate results, eCEA and cCEA were mostly compared, but the obtained data appeared more uniform (Table 4).

Table 4. Comparative Evaluation of Long-Term Results of Eversion and Classic Carotid Endarterectomy

Note: □ ― no statistically significant differences; ― reliably different results; ACVA ― acute cerebrovascular accident

Thus, S. Demirel, et al., analyzing the long-term results (follow-up period of 24 months) of 206 eCEA and 310 cCEA, noted higher rates of ipsilateral ACVA with the second method of the intervention (0% vs. 2.9%) [26]. In a randomized study, D. M. Markovic, et al. comparing 103 cases of the eversion method and 98 cases of the classic method (follow-up period of 38 months), the incidence of ICA restenoses was lower in the first group (0% vs. 6.1%) [24]. A lower frequency of ICA restenosis in the long-term period (from 12 to 76 months) in the eversion method compared with the classic one (8,550 eCEA and 7,721 cCEA), was also noted in the meta-analysis by S. N. Antonopoulos, et al. [15].

Similar results are given in Russian publications. In the study of P. O. Kazanchyan, et al., the long-term results of 570 eCEA and 243 cCEA were compared (the follow-up period up to 15 years without specifying the mean follow-up period). According to the authors, ICA restenoses were diagnosed almost 3 times less often (3.5% vs. 9.8%) after the eversion method of carotid reconstruction [25]. A. N. Kazantsev, et al. found a two-time difference in the frequency of re-occlusions (5.2% vs. 2.8%) and restenoses (4.2% vs. 2.1%) after use of eversion and classic methods (follow-up period up to 4 years) [11]. Meta-analysis by A. V. Gavrilenko, et al. (1,718 eCEA and 1,954 cCEA) showed a significant reduction of frequency of ACVA, as well as of restenoses, in the remote period of the eversion method of intervention as compared to the classic one [19].

In systematization of the data of Vascular Quality Initiative Database registry, the frequency of stroke/mortality and of restenoses in 1 year after the intervention with use of the primary suture, significantly exceeded those in eCEA in contrast to cases of using patches [18]. In meta-analysis by M. K. Lazarides, et al., the frequency of restenoses after eCEA was the lowest in comparison with any method of arteriotomy closure (direct suture/different kinds of patches) [20].

Unfortunately, there are few publications in the available literature concerning comparison of eCEA with ICA prosthetic repair. This is mostly due to the fact that the latter is used only when other methods entail a higher risk of complications, mainly as a repeated intervention due to complications developed in the early and late postoperative periods.

Nevertheless, according to the existing data, in particular, in the publication of Yu. V. Belov, et al. comparing the results of ICA prosthetics, eCEa and cCEA (n = 38, 30 and 40 patients, respectively, the follow-up to 24.5 months), the advantage of eCEA among other methods is demonstrated in terms of the incidence of ACVA and ICA restenoses. In case of eCEA, these parameters were 0 and 3%, while in cCEA they reached 3 and 18%, and in ICA prosthetic repair ― 3 and 6, respectively [14].

CONCLUSION

Concerning the immediate results of carotid reconstructions, the relation between the chosen method of intervention and the obtained results does not seem evident. Thus, a number of authors find a significant advantage in the eversion carotid endarterectomy [15, 17, 19], others do not see any significant difference between eversion and classic carotid endarterectomies [11, 16, 18, 20], unless it is a matter of using direct suture [16, 18, 20], which also refers both to meta-analyses [15, 16, 19, 20] and to the original studies [11, 17].

As for the long-term results, here the situation is more unambiguous: practically all the literature sources show better results of the eversion method [11, 15–17, 19, 20]. The only exclusion is the data of Vascular Quality Initiative Database, and only in the part where the direct suture was not used [18]. Besides, to note, this source uses the shortest follow-up period ― only 12 months.

Summarizing the above, one should admit that in carotid reconstructions, a method of choice is eversion carotid endarterectomy, if the peculiarities of lesion of the bifurcation of the carotid artery and relationship between the anatomical structures do not limit the possibility of using eversion method.

ADDITIONAL INFORMATION

Funding. This article was not supported by any external sources of funding.

Conflict of interests. The authors declare no conflicts of interests.

Contribution of the author: Author agree to be accountable for all aspects of the work.

About the authors

Dmitry F. Beloyartsev

Author for correspondence.
Email: beloyar@rambler.ru
ORCID iD: 0000-0002-7808-3454
SPIN-code: 6165-3667

MD, Dr. Sci. (Med.), Professor

References

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