CAROTID EVERSION ENDARTERECTOMY - SHORT-TERM AND LONG-TERM RESULTS

From January 1979 to December 1993, of 2723 carotid revascularizations performed on our service, 168 (6.2%) were isolated carotid eversion endarterectomies (CEEs) for atherosclerotic occlusive disease. Since 10 of these procedures were bilateral, there were 158 patients total (88 men and 70 women). Twenty-six (16.5%) had diabetes, 54 (34.2%) had coronary disease, and 107 (67.7%) had hypertension. The mean age was 68.9 +/- 8.9 years (range 38 and 85 years). Preoperative ischemic symptoms were hemispheric in 93 (55.4%) patients, retinal in 31 (18.4%), and vertebrobasilar in 37 (22%). They consisted of one or more strokes in 44 (26.2%) patients and one or more transient ischemic attacks in 99 (58.9%); 25 (14.9%) patients were asymptomatic. The operated lesion contained atherosclerotic stenotic plaque in all cases. The lesion was tightly stenotic (> 75%) and hemodynamically significant in 93 (55.4%) cases and irregular or ulcerated in all others. In 86 (51.2%) patients a coil or kink of the distal internal carotid artery was also present. The contralateral carotid artery was totally occluded in eight (4.7%) patients and tightly stenotic in seven (4.2%). All patients were operated on under deep general anesthesia; they were given systemic heparin and normal blood pressure was maintained. After freeing and cross-clamping of the carotid bifurcation, the end of the common carotid artery or the ostium of the internal carotid artery was sectioned. The section allowed a deep-plane endarterectomy through eversion and excellent control over the endarterectomized surface and its extremities. Since January 1989 completion arteriography has been routinely performed after GEE. There were three (1.9%) postoperative deaths in the series (two due to ipsilateral ischemic stroke and one due to contralateral ischemic stroke in the context of congestive heart failure) and two (2.9%) nonlethal ischemic strokes (one ipsilateral and one contralateral). All CEEs were controlled using arteriography in 60 (35.7%) cases or duplex scanning in all others, and in all except one patency was confirmed in the postoperative period. The mean follow-up was 53 months (5 to 160 months). At 5 years the primary patency rate was 99.4% +/- 1.2% and the ipsilateral ischemic stroke-free rate was 93.2% +/- 5.7%. CEE is a fast, safe, easy, and satisfactory technique that avoids the stenotic consequences of a longitudinal arteriotomy and does not necessitate a patch. Provided that completion arteriography is possible, CEE should be used more often, especially when the carotid artery is elongated.