Hayrettin Levent MAVİOĞLU, Ufuk MUNGAN, Haydar CELASİN, Eren GÜNERTEM, Ertekin Utku ÜNAL

Karotis endarterektomide yama ve şanta gerçekten ihtiyacımız var mı?

Amaç: Karotis endarterektomi (KEA) ameliyatının semptomatik ve asemptomatik hastalarda inmeyi önlemedeki etkinliği bilinmektedir. Biz bu çalışmada şant kullanmadan, primer kapama tekniği ile gerçekleştirdiğimiz KEA operasyonlarının uzun dönem sonuçlarını paylaşmayı amaçladık. Gereç ve Yöntemler: Ekim 2013 ile 2019 tarihleri arasında şant kullanmadan primer kapama tekniği ile opere olan 122 hasta bu retrospektif çalışmaya dahil edildi. Doppler ultrasonografi (DUSG) rezidüel ve tekrarlayan darlıkların tespiti için primer görüntüleme yöntemi olarak kullanıldı. Takip süresince hastalar ikinci, altıncı aylarda ve sonrasında yıllık olarak yapıldı. Takiplerde ipsilateral serebrovasküler olaylar ve mortalite kayıtları alındı. Bulgular: Hastaların ortalama yaşı 69,1 ± 7,1 (48-90)’ydi. Median takip süresi 47 (5 - 78) aydı. 1 (0,8%) hastada hastane içi ölüm gerçekleşti. Erken dönemde; 1(0,8%) hastada ipsilateral sekel bırakan ve 1(0,8%) hastada da sekelsiz serebrovasküler olay izlendi. Yine 1(0,8%) hastada geridönüşümlü iskemik nörolojik defisit ve 1(0,8%) hastada kafaiçi kanama görüldü. Geç mortalite gelişen hasta sayısı 4 (3,3%) olarak kayıt edildi. Bunların 2 (1,6%)’si kardiyak nedenli ölümdü. Geç dönemde 3 (2,5%) hastada ipsilateral serebrovasküler hadise gelişti. Bunların 1 (0,8%)’i sekel bırakan, 1 (0,8%)’i sekel bırakmayan inmeydi. 1 (0,8%) hastada da geridönüşümlü iskemik nörolojik deficit görüldü. Geç dönemde DUSG sonuçlarına göre 4 (3,3%) hastada 50%’nin altında, 2 (1,7%) hastada 70%’in üzerinde darlık görüldü. 1 (0,8%) hastada da total oklüzyon meydana saptandı. Sonuç: Primer kapama tekniği ile KEA seçilmiş hastalarda kabul edilebilir erken ve geç dönem komplikasyon, düşük mortalite ve tekrarlayan darlık oranlarıyla uygulanabilir.

Anahtar Kelimeler:

karotis endarterektomi

Do we really need patch and shunt for carotid endarterectomy?

Aim: The efficacy of carotid endarterectomy (CEA) for stroke prevention in asymptomatic and symptomatic patients is well known. We aimed to share long term follow up results for primary closure technique for CEA without shunting and investigated risk factors for complications in this patient group. Material and Methods: Between September 2013-2019, 122 patients with isolated CEA with primary closure were enrolled in this retrospective study. Dopppler ultrasound (DUSG) scanning was used as the primary imaging tool for the determination of residual and recurrent stenosis. During the follow-up period duplex ultrasonography was performed in the second month, sixth month and annually thereafter. Ipsilateral cerebrovascular events and mortalities were recorded during follow up period. Results: The mean age was 69,1 ± 7,1 (48-90) years. The median follow-up time was 47 (5 to 78) months. Hospital mortality was reported in 1 patient (0,8%). Early postoperative cerebrovascular accident were seen as ipsilateral disabling stroke in 1 patient (0,8%), ipsilateral non-disabling stroke in 1 patient (0,8%), reversible ischemic neurological deficit (RIND) in 1 patient (0,8%) and massive intracranial bleeding in 1 patient (0,8%). Late mortality was reported in 4 (3,3%) patients. 2 (1,6%) were cardiac reasons and 2 (1,6%) were non cardiac reasons. During the follow-up period ipsilateral cerebrovascular accident (CVA) were seen in 3 patients (2,5%) and these were; ipsilateral disabling stroke in 1 patient (0,8%), ipsilateral non-disabling stroke in 1 patient (0,8%), RIND in 1 patient (0,8%).According to the latest duplex scanning during follow up period 4 (3,3%) patients had below 50% restenosis, 2 (1,7%) patients had above 70% restenosis and 1 (0,8%) patient had total occlusion. Conclusion: Primary closure technique for CEA can be used in selected patients with acceptable early and late complication rates, low mortality and low restenosis rate.

Keywords:

carotid endarterectomy, carotid artery disease carotid artery stenosis,

PDF

___

1. Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, Ferguson GG, Fox AJ, Rankin RN, Hachinski VC, Wiebers DO, Eliasziw M. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325: 445- 53.
2. European Carotid Surgery Trialists’ Collaborative Group. Randomized trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351: 1379-87.
3. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995; 273: 1421-8.
4. Halliday A, Mansfield A, Marro J et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet 2004; 363: 1491-502.
5. Biller J, Feinberg WM, Castaldo JE et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1998; 29: 554-62.
6. Gray-Weale AC, Graham JC, Burnett JR, Byrne K, Lusby RJ. Carotid artery atheroma: comparison of preoperative B-mode ultrasound appearance with carotid endarterectomy specimen pathology. J Cardiovasc Surg 1988; 29: 676-81.
7. Geroulakos G, Ramaswami G, Nicolaides A et al. Characterization of symptomatic and asymptomatic carotid plaques using high resolution real-time ultrasonography. Br J Surg 1993; 80: 1274-7.
8. Grant EG, Benson CB, Moneta GL et al. Carotid artery stenosis: gray-scale and Doppler US diagnosis-society of radiologists in ultrasound consensus conference. Radiology 2003; 229: 340-6.
9. Coward LJ, Featherstone RL, Brown MM. Safety and efficacy of endovascular treatment of carotid artery stenosis compared with carotid endarterectomy: a Cochrane systematic review of the randomized evidence. Stroke 2005; 36: 905-11.
10. Qureshi AI, Kirmani JF, Divani AA et al. Carotid angioplasty with or without stent placement versus carotid endarterectomy for treatment of carotid stenosis: a meta-analysis. Neurosurgery 2005; 56: 1171-9.
11. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ . 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/ SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. Vascular Medicine 2011; 16: 35–77.
12. Jordan WD Jr. Carotid artery stenting remains inferior to carotid endarterectomy for most patients. Review. Tex Heart Inst J 2013; 40: 589-90.
13. SPACE Collaborative Group, Ringleb PA, Allenberg J, Bruckmann H, Eckstein HH, Fraedrich G et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368: 1239-47.
14. Brott TG, Hobson RW 2nd, Howard G et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363: 11-23.
15. Mannheim D, Weller B, Vahadim E, Karmeli R. Carotid endarterectomy with a polyurethane patch versus primary closure: a prospective randomized study. J Vasc Surg 2005; 41: 403-7
16. Ho KJ, Nguyen LL, Menard MT. Intermediate-term outcome of carotid endarterectomy with bovine pericardial patch closure compared with Dacron patch and primary closure. J Vasc Surg 2012; 55: 708-14.
17. Avgerinos ED, Chaer RA, Naddaf A, El-Shazly OM, Marone L, Makaroun MS. Primary closure after carotid endarterectomy is not inferior to other closure techniques. J Vasc Surg 2016; 64: 678-683.
18. Cao P, Giordano G, De Rango P et al. Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg 2000; 31: 19-30.
19. Ballotta E, Da Giau G, Saladini M, Abbruzzese E, Renon L, Toniato A. Carotid endarterectomy with patch closure versus carotid eversion endarterectomy and reimplantation: a prospective randomized study. Surgery 1999; 125: 271-9.
20. Zenonos G, Lin N, Kim A, Kim JE, Governale L, Friedlander RM. Carotid endarterectomy with primary closure: analysis of outcomes and review of the literature. Neurosurgery 2012; 70: 646-54.