Eversion technique versus traditional carotid endarterectomy with patch angioplasty: a systematic review with meta-analyses and trial sequential analysis

Abstract

Introduction: The use of an 'eversion' technique is not unequivocally proven to be superior to carotid endarterectomy with patch angioplasty. An up-to-date systematic review is needed for evaluation of benefits and harms of these two techniques.

Methods: RCTs comparing eversion technique versus endarterectomy with patch angioplasty in patients with a symptomatic and significant (≥50 %) stenosis of the internal carotid artery were enrolled. Primary outcomes were all-cause mortality rate, health-related quality of life and serious adverse events. Secondary outcomes included 30-day stroke and mortality rate, (a) symptomatic arterial occlusion or restenosis, and adverse events not critical for decision making.

Results: Four RCTs were included with 1272 surgical procedures for carotid stenosis; eversion technique n = 643 and carotid endarterectomy with patch closure n = 629. Meta-analysis comparing both techniques showed, with a very low certainty of evidence, that eversion technique might decrease the number of patients with serious adverse events (RR 0.47; 95% CI 0.34 to 0.64; p ≤ 0.01). However, no difference was found on the other outcomes. TSA demonstrated that the required information sizes were far from being reached for these patient-important outcomes. All patient-relevant outcomes were at low certainty of evidence according to GRADE.

Conclusions: This systematic review showed no conclusive evidence of any difference between eversion technique and carotid endarterectomy with patch angioplasty in carotid surgery. These conclusions are based on data obtained in trials with very low certainty according to GRADE and should therefore be interpreted cautiously. Until conclusive evidence is obtained, the standard of care according to ESVS guidelines should not be abandoned.

Keywords: Blood pressure; Carotid endarterectomy; Eversion technique; Patch; Stenosis; Systematic review.

Fig. 1

Schematic anatomy of carotid artery in neck. Superior cervical ganglion (ganglion cervicale superius) lies at the level of the bifurcation of common carotid artery into the external carotid artery and the internal carotid artery. Illustration is re-used with permission of the publisher [18].

Fig. 2

Ways of reconstructing the carotid artery (bifurcation). CCA: common carotid artery, STA: superior thyroid artery, ECA: external carotid artery, ICA: internal carotid artery. A: Transection of the internal carotid artery. B: Reconstruction after the eversion technique. C: Longitudinal arteriotomy. D: Reconstruction of the longitudinal arteriotomy with patch angioplasty.

Fig. 3

Outcomes prioritized according to importance to patients (critical for decision making) undergoing carotid surgery for symptomatic carotid stenosis (GRADE 2008). *<30 days and long term (>30 days). GRADE: Grading of Recommendations, Assessment, Development and Evaluation.

Fig. 4

Flow diagram summarizing the search process and results of each phase of the systematic review. doi:https://doi.org/10.1371/journal.pmed1000097 (Moher 2009).

Fig. 5

risk of bias summary of all included trials, the eight criteria on the X-axis. Name of first author and year of trial on Y-axis. + = adequate. − = inadequate. ?-mark = unclear.

Fig. 6

forest plot on all-cause mortality after ET or CEAP. Random-effects model. A: forest plot on all-cause mortality. Best case scenario ET. B: forest plot on all-cause mortality. Worst case scenario ET.

Fig. 7

forest plot on serious adverse events after ET or CEAP. Random-effects model.

Fig. 8

forest plot on <30-day stroke after ET or CEAP. Random-effects model.

Fig. 9

forest plot on <30-day (procedure related) mortality after ET or CEAP. Random-effects model.

Fig. 10

forest plot on asymptomatic restenosis ≥ 50 % or occlusion after ET or CEAP. Random-effects model. A: forest plot on asymptomatic restenosis ≥ 50 % or occlusion. Best case scenario ET. B: forest plot on asymptomatic restenosis ≥ 50 % or occlusion. Worst case scenario ET.