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Long-term Results of Eversion Carotid Endarterectomy

James H. Black, MD, David C. Chang, PhD, Joseph Ricotta, MD and Calvin E. Jones, MD,
Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center Baltimore,  MD

Objective: Carotid endarterectomy (CEA) is supported by Level 1 evidence as the standard of care for symptomatic and asymptomatic extracranial carotid stenosis. Eversion carotid endarterectomy (ECEA) has been proposed as an acceptable alternative to the standard bifurcation endarterectomy in many patients; however, long term follow-up of this technique has not been reported. This study was designed to analyze the long-term durability of ECEA in symptomatic and asymptomatic patients.
Methods: From June, 1989 to March, 2002, 534 ECEAs were performed on 485 patients (60% male, 44% symptomatic, reoperative 1.0%). Preoperative characteristics, operative findings, and postoperative duplex data were entered prospectively into database. This data was retrospectively reviewed to determine the incidence of major adverse cardiovascular events within 30 days of surgery (MACE), late survival and the late incidence of ipsilateral carotid disease. Variables associated with carotid restenosis were subjected to statistical analysis.
Results: The mean follow-up period was 6.86 years (95% CI, 6.56-7.16; median 6.6y). MACE occurred in 19 patients (3.8%), including 13 strokes (2.6%) and 6 deaths (1.2%). MACE when added to surgical site related complications yielded a <30 day complication rate of 5.3%. Survival by life table analysis at 5 and 10 years was 75.2% and 50.1%, respectively. Recurrent stenosis of the ECEA site was noted in 20 patients (4.1%) with a mean time to recurrence of 4.4 years (95% CI, 2.92-6.07; median 4.0y). Statistical analyses failed to implicate any specific patient risk factor, symptomatic presentation, presence of hyperlipidemia or statin use, ICA diameter, or presence of residual disease as predictive of recurrent stenosis.
Conclusions: The current study represents the longest published follow-up to date of patients undergoing ECEA. The findings of this study support eversion carotid endarterectomy as a safe and durable long-term treatment for extracranial carotid disease presenting with and without acute symptomatology.