Posterior transverse plication of the internal carotid artery to correct for kinking

The occasional need for shortening of the internal carotid artery (ICA) following carotid endarterectomy (CEA) to correct for kinking is still controversial. Although several technical options have been suggested, the impact on perioperative outcome remains unclear, and long-term clinical follow-up is lacking. Shortening by resection has a theoretical risk for a twisted anastomosis and subsequent ICA thrombosis. Posterior transverse plication (PTP) offers an alternative shortening technique without the need for a new anastomosis. We aimed to assess the safety and patency of CEA with concomitant PTP. Secondly, we aimed to provide an overview of different technical modalities for shortening of the carotid artery in current literature.

Within the time frame of 2000 through 2011, 29 patients (mean age, 73.4 years) undergoing CEA with additional PTP of the ICA and standardized patchplasty were retrospectively identified. Patient characteristics, surgical procedural details, and both short- (<30 days) and long- (>30 days) term clinical and duplex ultrasound follow-up were retrieved. Restenosis was defined as ≥50% stenosis on duplex ultrasound. In addition, a literature search was performed on different techniques for ICA shortening.

Thirty-day outcome revealed no deaths or strokes. No postprocedural thrombosis or narrowing of the ipsilateral ICA was observed. During follow-up (mean, 34.3 months; range, 3-125 months), one patient (4%) died of a noncardiovascular cause. Three patients (11%) developed ipsilateral neurological symptoms (1 stroke, 2 transient ischemic attacks) after 5, 19, and 66 months follow-up, respectively. Of these, two patients (7%) had restenosis at the site of PTP. Asymptomatic restenosis occurred in one other patient (4%) after 16 months.

Although the indications for additional shortening procedures following CEA need to be defined, in this small series, PTP as an additional shortening procedure of the ICA following CEA seems feasible and safe with no additional periprocedural risk for narrowing at the plicature or thrombosis of the endarterectomy plane. However, restenosis at the plicature may hamper the long term benefit of carotid reconstruction.