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Restenosis After Eversion (EV) vs. Patch Closure (PC) Carotid Endarterectomy (CEA)

Objective: Recurrent stenosis, previously documented in 8.5% of our post-CEA patients at 5-years, is the “Achilles heel” of CEA. Among the technical advantages of EV is a perceived lower incidence of recurrence, although data to support this contention are conflicting. This study was designed to review late outcomes of EV vs. PC.
Methods: Between 1993-2003, 951 CEA were performed by a single surgeon with adoption of EV as the primary technique 1/1/2000. PC was used when shunting was required or for long ICA lesions. With minimum one-year follow-up and a current duplex-scan as inclusion criteria, complete follow-up data was available for 155 PC and 135 EV patients. Incidence of moderate (50-70%;ICA/CCA 2-4 or EDV>100-139) and severe (≥70%;ICA/CCA>4 or EDV>140) restenosis was examined at 1 month and >1 year. Study end-points of survival, stroke-free survival and freedom from restenosis (moderate and severe) were assessed by actuarial methods.
Results: There were no differences in demographic/clinical parameters, indication for surgery (69% overall asymptomatic), or early perioperative stroke/death (1.0% overall) between PC vs. EV patients. Actuarial survival at 5-years was similar in PC(88±3%- mean follow-up 5.5 years) and EV(92±3%-mean follow-up 3.5 years). Any early restenosis (single case of severe in each group) occurred in 5.8% PC vs. 6.7% EV(p=0.76). By actuarial methods, severe restenosis occurred at 1.8%/year in PC and 1.4%/year in EV. Cumulative freedom from moderate or severe restenosis at 3 and 5 years were similar (PC:79±4% and 66±6%; EV:83±4% and 72±8%,p=0.90), with corresponding figures for severe restenosis (PC:94±2% and 91±4%; EV:93±3% and 93±3%,p=0.52). Re-intervention rates were 3.0%(EV) vs. 4.5%(PC), (p=0.49). Three late strokes occurred (1 related to the reference carotid) in PC and none in EV.
Conclusion: Despite technical advantages of EV in certain situations (ICA redundancy or kinking), these data support similar clinical and anatomic outcomes between PC and EV.