Carotid Endarterectomy Using Patch Angioplasty without Routine Completion Duplex Scan

ABSTRACT

PURPOSE: Routine intraoperative duplex color-flow ultrasound carotid examination as a completion study has been welcomed by many vascular surgeons as the most recent, high proficiency tool to detect unsuspected remaining operative defects before the patient leaves the operating room, thereby improving operative outcome after Carotid Endarterectomy (CEA). However, after many years of experience gaining added knowledge about the clinical course and standardization of operative procedures of CEA for mainly occidental patients, the adherence to strict operative procedures using patch angioplasty and liberally added continuous-wave Doppler confirmation has been found to achieve well beyond acceptable operative results in our patients without routine intraoperative duplex scanning (IDS). METHODS: A retrospective review of 455 surgical patients who underwent patch angioplasty in a five year period, from January 1996, was performed to evaluated their operative outcome. Their perioperative morbidity, mortality, and follow up Duplex scan findings on restenosis for a mean of 20.8 months were observed for a comparison between our experience and recently reported results using routine IDS. RESULTS: We had a perioperative combined stroke-death rate of 2.0% (n=9), consisting of death in 0.9% (n=4) and stroke in 1.1% (n=5). Residual stenosis was confirmed by first follow up Duplex scanning in 13 patients a (4.2%), 6 of whom were resolved with time. Twenty-three (5.6%) recurrent stenoses, including 2 occlusions and 1 high grade stenotic internal carotid artery (ICA), and 1 occlusion with 2 severe stenoses in external carotid artery (ECA), appeared among 414 cases during follow up. Except for 2 patients who suffered perioperative stroke, one of whom died, all residual stenosis and recurrent stenosis patients stayed clinically symptom free. Among 5 immediate postoperative transient ischemic attacks (TIA) cases and 5 strokes, one residual stenosis accompanying stroke appeared during follow up. Of five cases that were re-explored in the operating room by continuous wave Doppler information with conversion of primary closure to patching (n=2) and revision of distal arteriotomy (n=2), all remained normal during follow up by duplex scan. CONCLUSION: Routine patch angioplasty, meticulous surgical technique and continuous-wave Doppler information were enough to achieve an acceptable clinical outcome in our patients. IDS might be necessary selectively for concerned cases only.