The rationale for patch-graft angioplasty after carotid endarterectomy: early and long-term follow-up

A prospective study was undertaken in March 1980, at the Vascular Surgery Department of the Padua University, Medical School, to establish whether patch graft angioplasty is useful in preventing restenosls after carotid endarterectomy (CE). Seventy-four patients underwent 86 CE (bilateral in 12 cases) for atherosclerotic disease involving the carotid bifurcation. Thirty-eight (51.4%) patients presented TIA's or non hemispheric symptoms of cerebrovascular insufficiency; 30 (40.5%) were asymptomatic and 6 (8.1 %) had partial nonprogressing or fixed strokes. All operations were performed under general anesthesia, with pharmacologic hypertension and systemic heparinization; in all cases, continuous EEG monitoring and 'stump pressure' measurement were employed. The operation was performed without a temporary intraluminal shunt in the patients showing tolerance to carotid clamping. The protection of the shunt was required only in patients with EEG monitoring changes (17). All carotid arteriotomies were extended into the internal carotid artery to overpass the end of the endarterectomy. Overpass was also used in the proximal edge of the arterlotomy, in the common carotid artery. The distal intima was never fixed with stitches and the arteriotomy was routinely closed with a PTFE patch graft angioplasty. Early results of cerebral protection were excellent. No patient presented permanent or transient postoperative neurological problems and no patient died in the postoperative period for causes related to the operation. This is substantiated by results we achieved during the period 1970-1979 in 192 patients, when all carotid endarterectomies were routinely performed without a shunt, with figures of 2.5% of postoperative stroke and 1.5% of mortality. Longterm follow-up (from 6 to 36 months) was completed in 51 patients (60 operations). All patients were clinically evaluated and tested for patency of the endarterectomized vessel and the contralateral carotid artery by means of c.w. Dopplersonography and, occasionally, by Duplex scanning. Patency of the endarterectomized carotid artery with absence of hemodynamically significant lesions was well detected in all cases. There were 4 late deaths unrelated to cerebrovascular insufficiency. Two patients showed a neurologic deficit. They were investigated with carotidography: both presented intracranial lesions. The absence of carotid restenosis, documented with noninvasive cerebrovascular testing, confirms that the closure with patching effectively delays and prevents this complication by means of a mechanism related to the compensation of the volumetrical increase either of the new atherosclerotic plaque or neointimal hyperplasia. The authors believe that-direct closure of the vessel is the primary cause of recurrent stenosis and therefore recommend routine patch graft angioplasty after carotid endarterectomy.