Restenosis After Carotid Endarterectomy Performed With Routine Intraoperative Duplex and Patching: A Modern Series

Introduction and Objectives: Restenosis rates of 5-15% have been reported after carotid endarterectomy (CEA). We undertook this investigation to determine whether the routine practice of carotid patching and intraoperative completion duplex ultrasonography would result in lower rates of carotid restenosis after CEA.
Methods: All consecutive carotid endarterectomies performed between 2000 and 2004 at a single institution were reviewed retrospectively. Patients underwent CEA using a longitudinal arteriotomy, followed by routine patching and intraoperative completion duplex ultrasonography. Only patients with at least one postoperative duplex scan performed at minimum 180 days after CEA were included.
Results: During the five-year study period, 407 consecutive carotid endarterectomies were performed, with 30-day stroke and mortality rates of 1.8% and 1.7%, respectively. 217 patients (53%) had one or more duplex ultrasound examinations performed at least 180 days post CEA; the mean follow-up duration was 692 days. Patch closure was employed in 99% of patients (51% Dacron, 48% bovine pericardium), and 98% of patients underwent intraoperative duplex scanning. In 8% of cases, reopening of the patch was required in order to correct an ultrasound visualized defect. These interventions targeted the external carotid artery (44%), the common carotid artery (33%), the endarterectomy site itself (11%), and the internal carotid artery distal to the endarterectomy site (11%). Ipsilateral restenosis greater than 50% was identified in 7 patients (3.1%) and was initially detected at a mean of 470 days. Within the more clinically relevant range of stenosis, 70-99%, the incidence of restenosis was 1.8% and was detected at a mean of 496 days. Of the patients who underwent intraoperative intervention based on the results of the completion duplex study, none experienced restenosis, stroke, or death.
Conclusions: CEA that is performed with routine patching and intraoperative duplex completion ultrasonography is a safe, durable operation with restenosis rates below those commonly reported.