Carotid Patching: What is the Optimum Patch Material?

Abstract

A growing body of evidence indicates that obligatory or highly frequent carotid endarterectomy (CEA) patch reconstruction gives superior peri operative and late outcomes. With average combined perioperative stroke and mortality rates for CEA in the 5 to 6% range, the 3 to 4% improvement in this outcome offered by patching is clinically highly significant. A major unanswered question is which patch material or materials provide the optimal protection against perioperative stroke and restenosis. Only two prospective randomized studies contain two or more carotid patch materials, and, like nonrandomized reports containing two or more patch materials, the sample sizes are too small to draw accurate statistical conclusions. This problem is circumvented by an infor mal meta analysis of pooled data from published reports containing outcomes for CEA patch reconstruction with two or more of the following materials: autolo gous greater saphenous vein, everted or double-layered cervical vein, Dacron, and polytetrafloroethylene (PTFE). The results indicate that saphenous vein is the best CEA patch material in terms of the two major end points—perioperative stroke and restenosis. However, everted cervical vein gives outcomes that are almost as good as saphenous vein. The synthetics Dacron and PTFE are clearly inferior to saphenous vein, with Dacron being the poorest performing commonly used CEA patch material. The best possible perioperative and long-term outcomes for CEA are most likely to be obtained with complete internal CEA end points and highly frequent patch reconstructions with autologous greater saphenous veins.