Outcomes following Eversion versus Conventional Endarterectomy in the Vascular Quality Initiative Database

Abstract

Background: Although the majority of vascular surgeons perform conventional carotid endarterectomy (c-CEA), others prefer eversion CEA (e-CEA). Despite several randomized controlled trials and single center studies, the advantage of one technique over the other is still not clearly defined. The purpose of this study is to compare the postoperative outcomes and durability of c-CEA versus e-CEA in a nationally representative cohort.

Methods: We performed a retrospective review of the Vascular Quality Initiative database between 2003 and 2018. Patients with prior ipsilateral carotid intervention (CEA and carotid artery stenting) and those undergoing concomitant procedures were excluded. Multivariable logistic and Cox-regression analyses were used to compare risk-adjusted perioperative and 1-year outcomes (stroke, death, and high-grade restenosis [>70%]) between c-CEA (using direct closure or patch angioplasty) and e-CEA.

Results: A total of 95,726 CEA cases were included, of which 12,050 (12.6%) were e-CEA and the remaining (87.4%) were c-CEA. Patch angioplasty was used in 94.9% of c-CEA compared with 49.7% of e-CEA (P < 0.001). On univariable analysis, no difference in perioperative outcomes was noted between the 2 approaches except for higher rates of in-hospital dysrhythmia (1.5% vs. 1.3%) and postprocedural hemodynamic instability (27.3% vs. 24.3%) after c-CEA compared with e-CEA (all P < 0.05). On the other hand, e-CEA patients were more likely to return to the operating room for bleeding (1.3% vs. c-CEA: 0.9%, P < 0.001). The outcomes of e-CEA did not differ if the common carotid artery was closed primarily or with a patch. After adjusting for potential confounders and stratifying with respect to patch use, there was no significant difference in outcomes between e-CEA and c-CEA when a patch is used in both procedures. However, when no patching was performed, e-CEA was associated with lower stroke/death at 30 days (odds ratio 0.72, 95% confidence interval [CI] 0.54-0.95, P = 0.02) and at 1 year (hazard ratio 0.75, 95% CI 0.58-0.97, P = 0.03).

Conclusions: Both e-CEA and c-CEA are safe and durable techniques with similar stroke/death and restenosis rates up to 1-year of follow up, as long as c-CEA is performed with patch angioplasty. However, e-CEA is superior to c-CEA without patch angioplasty and is associated with 28% and 25% reduction in 30-day and 1-year stroke/death, respectively.