Partial Eversion Carotid Endarterectomy: 17-Year Outcomes in 525 Consecutive Patients Support Safety and...

Carotid endarterectomy (CEA) is the established surgical intervention for stroke risk reduction in patients with significant carotid artery stenosis. Partial eversion carotid endarterectomy (PECE) is a modified operative technique using an oblique anterior wall arteriotomy at the carotid bifurcation, preserving the posterior arterial wall and allowing efficient plaque removal without patch closure. This study presents the largest single-center series of PECE, extending our original 2017 report with a further eight years of surgical practice. The 17-year period refers to the span of consecutive practice sampled rather than the duration of follow-up of individual patients; all endpoints are perioperative or early postoperative. The objective was to determine whether the favorable outcomes observed during the developmental phase of the technique were maintained across a subsequent era of mature practice.

Retrospective analysis of a prospectively maintained clinical database of all consecutive patients undergoing PECE at a single regional vascular center in the United Kingdom between October 2006 and February 2023. All procedures were performed by a single consultant vascular surgeon, for whom PECE was the default technique applied without anatomical preselection to all patients judged to benefit from endarterectomy. Two chronological cohorts were defined: original (2006-2015, n = 352) and extended (2016-2023, n = 173). Demographic data, operative details, 30-day neurologic outcomes, cranial nerve injuries, and duplex-confirmed restenosis rates were recorded. Between-cohort comparisons used the Mann-Whitney U test for continuous variables and Fisher exact test for categorical outcomes; P < .05 was considered significant. Thirty-day outcomes were additionally stratified by indication, and exact 95% confidence intervals (CIs) were calculated for all event rates.

A total of 525 patients underwent PECE over 17 years. Median age was 70 years (range, 44-96 years); 60.6% were male. Local anesthesia was used in 99.2% of cases. Median ICA clamping time was 14 minutes (interquartile range [IQR], 11.5-17 minutes) and median operative time was 41 minutes (IQR, 36-43 minutes in the original cohort), remaining stable across both cohorts (P = .81 and P = .72, respectively). The combined 30-day stroke rate was 1.3% (n = 7; 95% CI, 0.54-2.73) and mortality 0.4% (n = 2; 95% CI, 0.05-1.37). Both deaths occurred in patients who had sustained a perioperative stroke; expressed as the number of patients experiencing either outcome, the combined 30-day stroke/death rate was 1.3% (n = 7; 95% CI, 0.54-2.73). Stratified by indication, the 30-day stroke/death rate was 1.41% (6/425; 95% CI, 0.52-3.05) in symptomatic patients, 1.64% (1/61; 95% CI, 0.04-8.80) in asymptomatic patients, and 0% (0/39; 95% CI, 0.00-9.03) in patients undergoing endarterectomy before cardiac surgery. Perioperative transient ischemic attack (TIA) occurred in 1.0% (n = 5), all resolving before discharge. No significant cranial nerve injuries were recorded. No restenosis of 50% or greater was identified during longitudinal duplex surveillance to 24 months in the 185 patients of the original cohort subject to that protocol; among the remaining patients of either cohort, a single duplex scan at 4 to 6 weeks demonstrated no early technical abnormality, a study that cannot exclude subsequent restenosis. Outcomes remained stable across both chronological periods (P > .05 for all endpoints).

PECE is a safe, reproducible, and technically efficient technique for CEA with 30-day outcomes consistently meeting internationally accepted thresholds across 17 years and 525 consecutive procedures. The principal contribution of this updated series is the demonstration that favorable outcomes were maintained over a further eight years of clinical practice, with the addition of 173 cases increasing the total cohort by almost 50%. Extended per-patient surveillance was not undertaken, and the durability of the technique beyond the perioperative period therefore remains to be established. PECE warrants evaluation in prospective multicenter and randomized studies.