Modified eversion carotid endarterectomy

Eversion carotid endarterectomy is a well-described technique for carotid endarterectomy (CEA). The advantage of this technique is a completely autogenous repair. We describe a modification of eversion endarterectomy (MEE) that expeditiously extracts the plaque through a linear incision over the common carotid artery and the proximal bulbous internal carotid artery (ICA) only, allowing primary closure. Selective shunting can also be performed without difficulty.

A retrospective review of CEAs using MEE at two institutions by three vascular surgeons during a 5-year period was performed. Data were collected from the medical records, with institutional review board approval. Information regarding neurologic symptoms, degree of ICA stenosis, CEA technique, ICA clamp time, shunting, electroencephalographic monitoring, and postoperative complications was tabulated. Rate of significant restenosis (stenosis >50% by duplex criteria) was also calculated during the follow-up period.

Between 2005 and 2009, a total of 221 patients underwent MEE for carotid artery stenosis (CAS): 69 patients (31%) underwent MEE for symptomatic and 152 (68.8%) underwent MEE for asymptomatic CAS. Neuromonitoring in the form of electroencephalography was used in 85 (39%) patients, and an intraluminal shunt was used in 29 patients (13%) who had either severe contralateral disease or a previous ipsilateral cerebral infarction. Postoperative complications included transient ischemic attack (four, 2%), cerebral infarction (three, 1%), myocardial infarction (three, 1%), and hematoma (six, 3%). Four patients (2%) required a return to the operating room (OR). within 24 hours for hematoma (one, 1%) or postoperative neurologic deficit (three, %). The 30-day mortality was 1%. One patient (1%) required patch angioplasty because of the extent of disease and inability to obtain a good end point. Average cross-clamp time for MEE was 12.8 minutes. Two patients (1%) were reported to have hemodynamically significant restenosis within 2 years, with one patient requiring intervention.

MEE is a safe and effective way of treating CAS, with acceptable morbidity, mortality, and low rate of recurrent stenosis despite the absence of a patch. Given the brief clamp time required, routine shunting and/or neuromonitoring for this technique may have questionable clinical value and expense.