Regarding: "Patching versus primary closure for carotid endarterectomy"

Abstract

We read the article by Rockman et al with great interest, but do not support the conclusions that primary closure during carotid endarterectomy should be abandoned in favor of either eversion endarterectomy or endarterectomy with patch angioplasty. The primary closure group comprised only 11.8% of the study group. This suggests that this particular technique may have been practiced by surgeons performing fewer carotid endarterectomies than their peers. There is some evidence to support a volume-outcome relationship for carotid endarterectomy. It would be interesting to know if those surgeons performing primary closure had a smaller workload than those using patch closure and eversion endarterectomy.

No mention is given regarding the use of quality control to determine the technical success of carotid endarterectomy. The use of completion imaging has coincided with an improvement in outcome in many centers, although cause-and-effect is very difficult to prove. During the last 14 years, we have performed 675 consecutive carotid endarterectomies. The primary patch rate was 9.4% based upon small diameter vessels and technical problems with the distal endarterectomy site. A further 3.7% of patients had secondary patching based upon the findings of completion duplex scanning performed after primary closure of the artery but before closure of the wound. The stroke and death rate for the primary closure group was 13 (2.2%) of 586, and that of the patched group was 2 (2.2%) of 89. This stroke and death rate is exactly the same as the best results reported by Rockman et al using eversion endarterectomy and patch closure.

The Cochrane review strongly supports the use of patching; however, there are some drawbacks to obligatory use of patch angioplasty. Patch closure does not necessarily abolish technical error. Carotid patching is also not without risks. Not only is it associated with a longer cross-clamp time than primary closure, but vein patch may be susceptible to central rupture or the development of false aneurysms, and prosthetic patches carries a risk of graft sepsis.

There is a danger in publishing papers such as Rockman’s that they will be used as evidence in a court of law against a poor outcome using primary closure. Our data indicate that primary closure with selective patching is a safe technique when used in conjunction with quality control in the form of duplex completion imaging. We would strongly recommend completion imaging rather than a particular technique when performing carotid endarterectomy.