Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
Division of Vascular Surgery, Albany Medical College, Albany, NY.
J Vasc Surg. 2021 Aug;74(2):666-675. doi: 10.1016/j.jvs.2021.02.051. Epub 2021 Apr 20.
Which type of closure after carotid endarterectomy (CEA), whether primary, patching, or eversion, will provide the optimal results has remained controversial. In the present study, we compared the results of randomized controlled trials (RCTs) and systematic meta-analyses of the various types of closure.
We conducted a PubMed literature review search to find studies that had compared CEA with primary closure, CEA with patching, and/or eversion CEA (ECEA) during the previous three decades with an emphasis on RCTs, previously reported systematic meta-analyses, large multicenter observational studies (Vascular Quality Initiative data), and recent single-center large studies.
The results from RCTs comparing primary patching vs primary closure were as follows. Most of the randomized trials showed CEA with patching was superior to CEA with primary closure in lowering the perioperative stroke rates, stroke and death rates, carotid thrombosis rates, and late restenosis rates. These studies also showed no significant differences between the preferential use of several patch materials, including synthetic patches (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del], Acuseal [Gore Medical, Flagstaff, Ariz], polytetrafluoroethylene, or pericardial patches) and vein patches (saphenous or jugular). The results from observational studies comparing patching vs primary closure were as follows. The Vascular Study Group of New England data showed that the use of patching increased from 71% to 91% (P < .001). Also, the 1-year restenosis and occlusion (P < .01) and 1-year stroke and transient ischemic attack (P < .03) rates were significantly lower statistically with patch closure. The results from the RCTs comparing ECEA vs conventional CEA (CCEA) were as follows. Several RCTs that had compared ECEA with CCEA showed equivalency of CCEA vs ECEA (level 1 evidence) with patching in the perioperative carotid thrombosis and stroke rates. At 4 years after treatment, the incidence of carotid stenosis was lower for ECEA than for primary closure (3.6% vs 9.2%; P = .01) but was comparable between patching and eversion (1.5% for patching vs 2.8% for eversion).
Routine carotid patching or ECEA was superior to primary closure (level 1 evidence). We found no significant differences between the preferential use of several patch materials. The rates of significant post-CEA stenosis for CEA with patching was similar to that with ECEA, and both were superior to primary closure.
颈动脉内膜切除术（CEA）后哪种类型的缝合，无论是直接缝合、修补还是外翻，能提供最佳结果，一直存在争议。在本研究中，我们比较了各种类型缝合的随机对照试验（RCT）和系统荟萃分析的结果。
我们进行了 PubMed 文献检索，以查找比较直接缝合与修补、CEA 与修补和/或外翻颈动脉内膜切除术（ECEA）的研究，重点是 RCT、先前报道的系统荟萃分析、大型多中心观察性研究（血管质量倡议数据）和最近的单中心大型研究。
比较直接修补与直接缝合的 RCT 结果如下。大多数随机试验表明，与直接缝合相比，CEA 加修补可降低围手术期卒中率、卒中死亡率、颈动脉血栓形成率和晚期再狭窄率。这些研究还表明，几种补丁材料的优先使用没有显著差异，包括合成补丁（聚对苯二甲酸乙二醇酯[涤纶；杜邦公司，威尔明顿，DE]、Acuseal[戈尔医疗公司，弗拉格斯塔夫，AZ]、聚四氟乙烯或心包补丁）和静脉补丁（隐静脉或颈静脉）。比较修补与直接缝合的观察性研究结果如下。新英格兰血管研究组的数据显示，补丁的使用率从 71%增加到 91%（P<0.001）。此外，1 年再狭窄和闭塞（P<0.01）和 1 年卒中及短暂性脑缺血发作（P<0.03）的发生率也有统计学意义地降低。比较 ECEA 与常规 CEA（CCEA）的 RCT 结果如下。几项比较 ECEA 与 CCEA 的 RCT 表明，ECEA 与 CCEA 加修补在围手术期颈动脉血栓形成和卒中率方面具有等效性（一级证据）。治疗后 4 年，ECEA 的颈动脉狭窄发生率低于直接缝合（3.6%比 9.2%；P=0.01），但与修补和外翻相似（修补 1.5%，外翻 2.8%）。
常规颈动脉修补或 ECEA优于直接缝合（一级证据）。我们发现几种补丁材料的优先使用没有显著差异。CCEA 加修补的 CEA 后狭窄发生率与 ECEA 相似，均优于直接缝合。
