Carotid graft replacement: a durable option.

Background: Carotid artery bifurcation reconstruction after endarterectomy has been refined over the years. Methods including primary closure, patch closure, and eversion endarterectomy have been proven to be durable. However, there are patients who require more complicated reconstructions in primary or recurrent disease management. Carotid replacement with a prosthetic interposition graft is potentially a durable option to reconstruct an artery that is technically unsuitable for primary or patch closure.

Methods: The charts of all carotid endarterectomies (n = 482) performed by the authors at our institution between January 1999 and December 2003 were retrospectively reviewed. Follow-up was performed in an Intersocietal Commission for the Accreditation of Vascular Laboratories-accredited vascular laboratory. Patients were divided into two main groups: carotid replacement with 6-mm expanded polytetrafluoroethylene (ePTFE) (REP) or standard endarterectomy (CEA) with or without patch closure. The decision for REP vs CEA (as well as the type of closure) was at the discretion of the surgeon according to an assessment of the end point, the distal internal carotid artery, and the quality and length of the endarterectomy segment. Interposition grafting with a 6-mm stretch of ePTFE from the transected common carotid to the transected internal carotid artery was performed in replacement reconstruction. The external carotid was ligated. Follow-up statistical analyses were performed with the Fisher exact test and analysis of variance for nominal values and t tests for continuous variables. Life table analyses were performed for patency and survival.

Results: Complete perioperative data were available for 478 of the 482 operations performed (including all REP cases) during the study. At least one duplex ultrasound scan in follow-up was documented in 84% (n = 402) of the patients. A total of 51 were in the REP group, and 427 received CEA (95.3% with patch closure). Preoperative demographics, preoperative symptoms, and degree of stenosis did not vary within the study groups. Three 30-day surgical deaths occurred. The perioperative stroke rate between groups was not statistically different (REP, 1/51 [1.9%]; CEA, 3/427 [0.70%]; P = .35). Long-term patency and stroke-free survival rates at 3 years exceeded 96% and did not vary significantly between groups. The presence of a patch in the CEA group had no influence on outcomes. Duplex follow-up scan averaged two studies for at least 14 months in each group. Significantly more REP cases were reoperative procedures.

Conclusions: Carotid interposition reconstruction with an ePTFE graft is an acceptable alternative in cases in which the standard technique would be technically difficult or compromising to the endarterectomy closure. Carotid ePTFE interposition graft replacement seems to be safe and durable and to have no increased perioperative risk or altered intermediate-term outcomes.