Processes of care for carotid endarterectomy: surgical and anesthesia considerations.

There are still some vascular surgeons who do not use carotid patching routinely in all patients undergoing CEA, however, based on the data presented in this review, there is Level 1 evidence to support the routine use of carotid patching. Meanwhile, there is no Level 1 evidence to support selective patching for CEA, however a Grade D recommendation may be used to recommend that primary closure can be safely practiced in a large ICA (>6mm). A meta-analysis/systemic review of well-conducted prospective randomized trials (Level 1 evidence) concluded that there was no difference in stroke/death rates between conventional CEA with patch closure and eversion CEA. The incidence of significant restenosis with eversion CEA is also similar to CEA with patch closure, however eversion CEA had a lower restenosis rate than patients undergoing CEA with primary closure. Prior to the GALA trial, there was insufficient evidence from randomized clinical trials comparing CEA under local anesthesia versus general anesthesia to support the superiority of either technique in reducing major perioperative events, i.e. stroke, MI, or death. However, the GALA trial concluded that the perioperative stroke/MI and death rates were equivalent in both techniques.