Patch angioplasty versus primary closure for carotid endarterectomy
Abstract
Background
Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke.
Objectives
To assess the safety and efficacy of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure.
Search methods
We searched the Cochrane Stroke Group Trials Register (last searched November 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to December 2001), EMBASE (1980 to December 2001) and Index to Scientific and Technical Proceedings (1980 to 2001). We also handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field.
Selection criteria
Randomised and quasi‐randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy.
Data collection and analysis
Two reviewers independently assessed eligibility, trial quality and extracted data.
Main results
Seven trials involving 1127 patients undergoing 1307 operations were available for analysis. The quality of trials was generally poor. Follow‐up varied from hospital discharge to five years. Carotid patch angioplasty was associated with a reduction in the risk of stroke of any type (OR 0.33, P = 0.004), ipsilateral stroke (OR 0.31, P = 0.0008), and stroke or death, during the perioperative period (OR 0.39, P = 0.007) and long term follow‐up (OR 0.59, P = 0.004). It was also associated with a reduced risk of perioperative arterial occlusion (OR 0.15, 95% CI 0.06 to 0.37, P = 0.00004), and decreased restenosis during long‐term follow‐up in five trials, (OR 0.20, 95% CI 0.13 to 0.29, P < 0.00001). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow‐up. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo‐aneurysm formation were recorded with either patch or primary closure. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long‐term all‐cause death rates
Authors' conclusions
Limited evidence suggests that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and restenosis. It would appear to reduce the risk of combined death or stroke and there is a non significant trend towards a reduction in all‐cause mortality.
PICOs
Plain language summary
Patch angioplasty versus primary closure for carotid endarterectomy
Evidence now suggests a benefit from using routine patch angioplasty during carotid endarterectomy. About 20% of strokes result from narrowing of the carotid artery (the main artery supplying blood to the brain). Carotid endarterectomy is an operation that involves opening the carotid artery to remove this narrowing and therefore, reduce the risk of stroke. However, there is a 2% to 10% risk of the operation itself causing a stroke. Some surgeons advocate the incorporation of a patch made out of either synthetic material or the patients own vein, into the arterial closure. This may help to reduce the risk of the artery being narrowed during suture placement and may, therefore, reduce the risk of recurrent blockage and consequent stroke and/or death. However, use of a patch may increase surgical difficulty and operation length. Furthermore, thin walled vein patches may rupture with potentially fatal consequences and synthetic materials are vulnerable to infection.
