Ten-Year Experience With Primary Repair and Selective Patch Angioplasty in Carotid Endarterectomy

Abstract

Introduction

Carotid endarterectomy (CEA) is a cornerstone in stroke prevention for patients with carotid stenosis, with closure techniques including primary, patch angioplasty, and eversion. The aim of this paper is to present a 10-year analysis of outcomes in patients undergoing primary repair and selective patch angioplasty in CEA.

Methods

A retrospective, single-center study including all consecutive patients undergoing elective CEA at our institution between 2014 and 2023. The Primary outcomes were technical success and 30-day overall survival, ipsilateral ischemic stroke, reintervention, and major adverse cardiac events (MACE) rates. The secondary outcomes were >30-day ipsilateral ischemic stroke, reintervention and primary patency. All outcomes were analyzed in relation to the carotid closure technique (primary closure, patch angioplasty, or eversion). A Generalized Linear Mixed Model (GLMM) was used to assess the association between closure technique and both early and late outcomes. Kaplan-Meier estimates were used to analyze follow-up outcomes depending on the closure technique.

Results

A total of 625 CEA procedures were performed on 577 patients [mean age: 71 ± 9 years; 30.7% female], comprising 87.4% primary repairs, 10.4% patch angioplasty, and 2.2% eversion CEA. Technical success was achieved in (n = 615, 98.4%) of the procedures, with no significant difference between repair types (P value .947). The mean follow-up duration was 60 ± 38.45 months. Early (<30-day) ipsilateral stroke and reintervention did not differ significantly across carotid repair groups. GLMM analysis showed that congestive heart failure (CHF) was a significant predictor of increased risk for stroke and MACE (OR: 8.870, CI 95% 2.046-38.451, P = .005) (OR: 7.037, CI 95% 1.902-26.038, P = .005), respectively. Regional anesthesia significantly lowered the risks of stroke (OR: 0.216, CI 95% .065-.721, P = .014) and MACE (OR: 0.380, CI 95% .158-.914, P = .032). Long-term (>30-day) ipsilateral stroke and 2-year primary patency were comparable across the groups. GLMM analysis of >30-day stroke revealed no statistically significant differences between patch and primary CEA (OR: 1.947, 95% CI: .321-11.819, P = .363). Neither age >80 years (n = 94, 15%) nor female sex (n = 177, 30.7%) were significantly associated with increased stroke risk (age: OR 0.524, 95% CI: 0.021-7.013, P = .415; sex: OR 0.524, 95% CI: 0.087-3.152, P = .370). The analysis of 2-year patency outcomes revealed no significant associations between patch vs primary CEA, sex, or age greater than 80 years. KM analysis revealed 3-year survival rates of 93% for primary repair, 99% for patch angioplasty, and 90% for eversion (P = .5). Stroke-free survival at 3 years was 95%, 94%, and 100%, respectively (P = .3).

Conclusion

No significant differences were observed in early or late stroke, mortality, or 2-year patency on adjusted analysis. KM analysis showed favourable 3-year freedom from ipsilateral stroke in the primary repair group. These results suggest that primary repair is a safe option in anatomically suitable patients and support a selective, patient-tailored approach to carotid artery closure, rather than a uniform strategy for all cases.