CAROTID ENDARTERECTOMY WITH RECONSTRUCTION TECHNIQUES TAILORED TO OPERATIVE FINDINGS

Purpose: Reconstruction techniques tailored to operative findings were applied to 466 consecutive carotid endarterectomies (CEA) performed on 408 patients over 5 years. The choice of reconstructive technique was based on the extent of the arteriotomy incision required to obtain a complete internal CEA endpoint, the ability to obtain a complete endpoint, and the quality or redundancy of the endarterectomized internal carotid artery (ICA) segment. The hypothesis was that a complete internal CEA endpoint and a tapered, smooth, nonkinked reconstruction minimize complications. Methods: Complete distal endpoint feathering was obtained in 437 (94%) CEA. Patch reconstruction was performed in the 429 (92%) CEA in which the arteriotomy extended distal to the ICA bulb. Before patching, 16 (3.4%) redundant endarterectomized ICA segments were shortened by transverse-eversion suture plication to prevent kinking. A saphenous vein interposition graft was used in nine (1.9%) CEA. The other 28 (6.0%) CEA had an arteriotomy that did not extend distal to the bulb and were primarily closed. Results: Two (0.4%) patients died of myocardial infarction in the hospital; one of these patients also had a stroke. Three (0.6%) patients had nonfatal strokes in the hospital. Five patients had hyperperfusion syndrome after CEA, one of which occurred without complications in the hospital. The other four occurred after discharge from the hospital. Three of these patients had a stroke, and two with strokes died. The combined 30-day mortality and nonfatal stroke rate was 2.1% for CEA and 2.4% for patients. There were no patch ruptures, false aneurysms, or ICA occlusions. Three patients had a > 50% diameter carotid artery stenosis 6 months after CEA. Conclusions: These results support an aggressive attempt to obtain a complete or optimal ICA endpoint with reconstruction techniques based on operative findings. Recognition of patients at risk for and treatment of hyperperfusion syndrome after CEA remains a clinical challenge.