PresentedVascular SurgFebruary 1, 20

1Division oHospital, Balti

2DivisionRochester, Bal

3Division oBayview Medi

CorrespondHospital, HarvUSA, E-mail:

Ann Vasc SurDOI: 10.1016/� Annals of VPublished onli

92

Long-Term Results of Eversion CarotidEndarterectomy

James H. Black III,1 Joseph J. Ricotta,2 and Calvin E. Jones,3 Baltimore, Maryland

Background: Carotid endarterectomy (CEA) is supported by level 1 evidence as the standardof care for symptomatic and asymptomatic extracranial carotid stenosis. Eversion CEA (ECEA)has been proposed as an acceptable alternative to the standard bifurcation endarterectomy inmany patients; however, long-term follow-up of this technique has not been reported. This studywas designed to analyze the long-term durability of ECEA in symptomatic and asymptomaticpatients.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. These data were retro-spectively reviewed to determine the incidence of major adverse cardiovascular events (MACEs)within 30 days of surgery, late survival, and the late incidence of ipsilateral carotid disease. Vari-ables associated with carotid restenosis were subjected to statistical analysis.Results: The mean follow-up period was 8.86 years (95% confidence interval [CI] 6.56-9.16,median 6.6). MACEs occurred in 19 patients (3.8%), including 13 strokes (2.6%) and six deaths(1.2%). MACEs when added to surgical siteerelated complications yielded a<30-day complicationrate 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 recurrenceof 4.4 years (95% CI 2.92-6.07, median 4.0). Statistical analyses failed to implicate any specificpatient risk factor, symptomatic presentation, presence of hyperlipidemia or statin use, internalcarotid artery diameter, or presence of residual disease as predictive of recurrent stenosis.Conclusion: The current study represents the longest follow-up to date of patients undergoingECEA. The findings of this study support ECEA as a safe and durable long-term treatment forextracranial carotid disease presenting with or without acute symptomatology.

INTRODUCTION

The efficacy of carotid endarterectomy (CEA) to

prevent stroke has been demonstrated as superior

to medical therapy in several large randomized

at the 19th Annual Winter Meeting of the Peripheralery Society, Steamboat Springs, CO, January 30 -09.

f Vascular and Endovascular Surgery, Johns Hopkinsmore, MD.

of Vascular and Endovascular Surgery, Mayo Clinicetimore, MD.

f Vascular and Endovascular Surgery, Johns Hopkinscal Center, Baltimore, MD.

ence to: James H. Black III, MD, Johns Hopkinsey 611, 600 North Wolfe Street, Baltimore, MD 21287,jhblack@jhmi.edu

g 2010; 24: 92-99j.avsg.2009.06.019ascular Surgery Inc.ne: September 7, 2009

trials.1-3 More recently, population-based studies

have demonstrated further improvements in stroke

and death rates after CEA, thus setting a high stan-

dard of care for comparison with evolving stent

therapies.4-6 Techniques for eversion CEA (ECEA)

have been evaluated in retrospective series,7,8

systematic reviews,9 and randomized trials10; and

ECEA has been proven a safe technique for extirpa-

tion of occlusive carotid lesions. While initial results

of carotid surgery have proven to be excellent, the

ability of CEA techniques to yield low rates of reste-

nosis in the long term has not been clearly defined.

As both surgical and endovascular therapies for

extracranial carotid disease evolve, initial results

will expectedly improve and long-term results of

competing therapies will assume greater therapeutic

relevance. As such, our study was designed to

analyze the long-term outcomes of ECEA in

symptomatic and asymptomatic patients.

Vol. 24, No. 1, January 2010 Long-term results of eversion CEA 93

MATERIALS AND METHODS

A database of consecutive ECEAs performed at

Johns Hopkins Bayview Medical Center was main-

tained prospectively using data entry into Microsoft

Access and exported to Excel (Microsoft, Redmond,

WA). From June 1989 until March 2002, 534 ECEAs

were performed on 485 patients. Only ECEAs were

included in the study, and carotid surgeries per-

formed in conjunction with other vascular recon-

structive surgeries were excluded. During the same

period, 126 standard CEAs were performed using

patch angioplasty and intraluminal shunting; these

were performed in the setting of a period of random-

ization between standard and ECEA techniques.

Thus, the demographic and anatomic profiles of

these standard CEA patients are no different from

those of ECEA patients; they had similar immediate

major adverse cardiovascular events (MACEs) (but

longer operative times by approximately 30 min,

less plaque excised [grams], and higher cost due to

patch cost) but were not compiled for long-term

follow-up and, thus, are not considered further.

Patient demographics, surgical indications, oper-

ative details, and postoperative courses were

recorded from hospital records and prior clinic

assessments. Comorbid conditions and risk factor

categories for subsequent analysis were identified

and recorded in the database using reporting stan-

dards as described by the Society of Vascular Surgery

ad hoc committee.11 MACEs (myocardial event,

stroke, death) were identified within 30 days of

surgery. Surgical site complications (i.e., wound

infection, hematoma, nerve injury) were identified

from the medical record and included in the total

<30-day complication rate along with MACEs.

Long-term outcomes were identified from

hospital and office medical records. When hospital

or office records were incomplete, the patient or

a relative was contacted directly by telephone

(n¼ 60, 12.3%). For patients who could not be con-

tacted (n¼ 45, 9%), the date of death was identified

from the Social Security National Death Index.

Restenosis was defined as requirement to reoper-

ate on the index ECEA side or >60% diameter

reduction on duplex ultrasonography by a peak

systolic velocity (PSV)> 200. Duplex ultrasonog-

raphy was performed within 1-2 months of the

ECEA and yearly thereafter in the Intersocietal

Commission for the Accreditation of Vascular Labo-

ratories (ICAVL)ecertified vascular laboratory at

Johns Hopkins Medical Institutions. Routine axial

imaging techniques and angiography were not

used routinely for postoperative evaluation or

corroboration of duplex findings.

Postoperative survival and restenosis were

computed using life tables and Kaplan-Meier esti-

mate. Dichotomous variables and outcomes were

analyzed in contingency tables using a Fisher exact

test. Univariate models for variables associated with

restenosis were assessed using hazard ratios (HRs).

Data were presented as averages ± standard deviation

(SD), and p< 0.05 was considered statistically

significant.

All procedures were performed under general

anesthesia using systemic anticoagulation with

unfractionated intravenous heparin during the

eversion phase of the operation. During the clamp

interval, hypertension (systolic pressure 160-

180 mm Hg) was allowed or induced pharmacolog-

ically. All patients received antiplatelet medication

perioperatively to include 1,300 mg aspirin and

500 mL intravenous dextran during the first 10 post-

operative hours. The ECEA technique was per-

formed by transection of the common carotid

artery, as described by Etheridge12 and depicted in

Figure 1. To provide adequate exposure for the

ECEA, the occipital artery and vein are divided

routinely. The hypoglossal nerve can then be swept

medially, exposing the internal carotid artery (ICA)

beyond the posterior belly of the digastric muscle.

This exposure permits routine ICA clamping

4-5 cm beyond the carotid bifurcation. The superior

thyroid artery is usually divided to facilitate mobili-

zation of the carotid bulb. After common carotid

transection just proximal to the superior thyroid

artery, a deep endarterectomy plane is developed

to separate the plaque from the external elastic

lamina, appreciated as a pink, smooth interface in

the cleavage plane. The eversion is developed first

from the external carotid artery, then into the

ICA. Intimal tacking sutures were not used. Endar-

terectomy of the common carotid artery is accom-

plished for at least 2 cm, and the plaque is

transected flush to maintain an adherent proximal

intimal surface. End-to-end anastomosis of the

common carotid artery can then be accomplished.

A 6-0 coated polyester suture was preferred over

monofilament polypropylene suture for the

common carotid anastomosis due to the propensity

of monofilament to pursestring and leave an hour-

glass anastomotic deformity. The common carotid

artery anastomosis is accomplished in a fashion

that allows direct visualization of the lumen (see

Fig. 1). Sutures are placed exactly anterior and

posterior and tied. The sutures are rotated to facili-

tate a rapid suture line formation. After flushing,

blood flow is restored first to the external carotid

artery and then to the ICA. Redundancy of the

ICA can be removed by overlapping the proximal

Fig. 1. Technique of ECEA. A The carotid mobilization

should include division of the vascular sling of the occip-

ital artery and vein branch of the external carotid artery,

which tethers the hypoglossal nerve in proximity to the

mid- and distal ICA. B The endarterectomy plane is

developed cephalad with retraction of the carotid

branches over the mandril of the plaque. C Sharp divi-

sion of the intimomedial plane flush against the common

carotid artery (CCA) eversion. DeF Anterioreposterior

suture placement facilitates rapid anastomotic

completion.

94 Black et al. Annals of Vascular Surgery

and distal transected ends of the common carotid

artery and shortening the length of the proximal

common carotid artery.

Electroencephalographic monitoring was not

performed to determine cerebral ischemia.

Intraluminal shunts were not employed in the

study, and carotid stump pressure was not assessed

routinely to evaluate collateral hemispheric circula-

tion. ECEA does allow passage of an intraluminal

shunt after the bulk of the internal carotid plaque

Table I. Medical comorbidities of patients

undergoing ECEA

% n

Aspirin use 94% 507

Heart disease 57% 278

Hypertension (>1 drug) 29% 119

Diabetes 13% 66

Vol. 24, No. 1, January 2010 Long-term results of eversion CEA 95

is completed, but the ECEAs in this series were per-

formed without an intraluminal shunt. Completion

intraoperative angiography using plate radiographs

was performed in the first 24 months of the series

but was found to have no clinical value. Thereafter,

only if continuous wave Doppler insonation sug-

gested residual stenosis was completion angiography

performed.

Renal insufficiency 11% 55

Tobacco use (current + recent) 62% 291

Hypercholesterolemia 73% 356

Drug-controlled 42% 204

Table II. Surgical indications and variables for

ECEA

n %

Asymptomatic 299 56%

Symptomatic 235 44%

TIA/TMB 142 26%

Stroke 93 17%

Reoperative 5 1%

Mean stenosis 79% ± 10.8% range 55-99%

Mean ICA diameter 4.16 ± 1.7 mm range 2.5-8

Operative time 126 ± 28 min range 67-270

Mean carotid

clamp time

18 ± 10 min range 12-35

RESULTS

There were 534 ECEAs performed on 485 patients

during the study interval. Sixty percent of the

patients were male (n¼ 291) and 40% female

(n¼ 194). The average age of the patients was 71

years (range 42-93). Medical comorbidities are

typical of patients with arteriosclerosis and are

summarized in Table I.

The indications for surgery (see Table II) were

asymptomatic, severe stenosis in 56% (n¼ 299)

and symptomatic lesions in 44% (n¼ 235). For

symptomatic disease, 26% (n¼ 142) were for tran-

sient ischemic attack (TIA) or episodic amaurosis

fugax and 17% were for stroke (n¼ 93). Average

operative time was 126 min, and average carotid

clamp time to perform the ECEA was 18 min (range

12-35). ICA diameter averaged 4.16 ± 1.7 mm, with

187 ECEAs (35%) having an outer diameter of

3.5 mm or less.

A total complication rate of 5.3% was noted

within 30 days of ECEA. Site complications were

noted in eight ECEAs (1.8%), with five cranial

nerve palsies (three CN XII, two CN X). None of

these cranial nerve events led to permanent deficit.

Wound hematoma was noted in three ECEAs,

requiring exploration; in all cases the bleeding site

was not the common carotid anastomosis. Death

occurred in six patients (1.2%), with half involving

major stroke and the remaining cardiovascular

events. There were 13 strokes , with recovery of

six ECEA patients, yielding a major permanent

stroke risk of 1.2%. Strokes were identified by the

operating surgeon and resident teams and

confirmed by formal neurological exam by a neurol-

ogist. A major cardiovascular event rate (MACE) in

the ECEA patients was 3.8% at 30 days.

The mean follow-up period was 8.86 years (95%

CI 6.56-9.16, median 8.6). Duplex evaluation of the

operated carotid was performed in 98.2% of patients

at year 1, 95% at year 2, and 90% at year 5. By

10 years, duplex evaluation was available in 75%

of surviving patients. Follow-up data for survival

were available for all 485 patients. Kaplan-Meier

curve estimates for survival were 75.2% at 5 years

and 50.1% at 10 years post-ECEA (see Fig. 2).

Fisher’s exact test failed to demonstrate any associa-

tion of gender ( p¼ 0.42), tobacco use ( p¼ 0.21),

hyperlipidemia ( p¼ 0.35), or statin use ( p¼ 0.65)

with survival.

Restenosis was identified in 20 patients (4.1%).

The mean time to recurrence was 4.4 years, with

a median of 4 years. Three of these restenosis

patients underwent redo ECEA without event; two

patients were treated with redo CEA by longitudinal

arteriotomy and Dacron patch angioplasty. Of these

five redo carotid surgeries, the indication was symp-

tomatic lesion in four. The remaining patients man-

ifested duplex criteria suggesting >60% stenosis,

but intervention was deferred due to stable veloci-

ties and asymptomatic state, patient preference, or

other mitigating medical comorbid event. Statistical

analysis (Fisher’s exact test) failed to implicate any

specific patient risk factordsymptomatic presenta-

tion ( p¼ 0.15), statin use ( p¼ 0.52), ICA diameter

<3.5 mm ( p¼ 0.28), or presence of residual disease

on intraoperative angiographydas predictive of

recurrent stenosis ( p¼ 0.76). Hyperlipidemia did

not reach significance in predicting restenosis, but

statistical analysis suggested an effect may be

present ( p¼ 0.08) (Fig. 3).

Fig. 2. Kaplan-Meier survival curves for 485 patients

after ECEA. Standard error of the mean <10% for all

points on graph.

Fig. 3. Freedom from restenosis >60% after ECEA. Stan-

dard error of the mean <10% for all points on graph.

96 Black et al. Annals of Vascular Surgery

DISCUSSION

Debakey et al.13 originally mentioned carotid tran-

section and eversion endartectomy for extended

common carotid artery lesions, as well as for ICA

straightening. Etheridge12 then realized a similar

technique could be used to safely evert the carotid

bifurcation and achieve a simple endarterectomy.

The advantage of this ECEA technique is the restora-

tion of a vessel that appears more anatomically and

physiologically normal, theoretically reducing

turbulence that would incite intimal hyperplasia.

The suture line is created across the bulb, where

intimal hyperplasia would be least expected to

produce significant luminal narrowing, as opposed

to longitudinal arteriotomy, which places a suture

line on the critical ICA outflow. Patch materials

are avoided, thus reducing infectious risk.

Patients in this series underwent ECEA without

intraluminal shunting. Our perioperative stroke

risk approximated most of the contemporary series

regarding CEA, which have reported major stroke

risks of 1-2% and included shunting to reduce cere-

bral ischemia.10,14-16 Our ECEA technique allows

for passage of an intraluminal shunt after the ICA

plaque has been removed. However, plaque

removal from the ICA is the most time-consuming

portion of the operation, the remaining common

carotid eversion (as shown in Fig. 1) is rapid, and

final closure is usually extremely simplified, taking

usually less than 2-3 min; thus, shunt placement is

not likely to produce meaningful time savings. On

average, the total cross-clamp time was 18 min,

during which systemic hypertension was main-

tained to encourage collateral flow. Our contention

is stroke after ECEA is embolic in nature. Intraoper-

ative cerebral ischemia is considered to be a rela-

tively uncommon cause of embolic stroke.17-19

Indeed, in analysis of 66 strokes in a series of over

3,000 carotid surgeries performed with selective

shunting, 65% of strokes were thought to be attrib-

utable to technical errors in the CEA and contralat-

eral occlusion (wherein cerebral ischemia would be

theoretically highest) was not an independent

predictor of stroke.20 While it cannot be denied

that ICA clamping may produce cerebral ischemia

in some patients, it is likely such ischemia is reversed

with either shunting or opening flow after clamp

removal on the carotid territory. Magnetic reso-

nance imaging with diffusion-weighted imaging

was not available during the entire study interval

to interrogate the distinction of embolic or water-

shed infarct, but our clinical position is supported

by our experience in three of our ECEA patients

with major strokes, who awoke immediately with

major deficit and immediate exploration revealed

plateletefibrin aggregates lining the endarterec-

tomy plane.

The long-term survival of our patients was similar

to that in many series describing outcomes in the 5-

and 10-year time frame.14,21 Other studies have

demonstrated that hyperlipidemia or statin use influ-

ences mortality unfavorably14 or favorably,22,23 but

our statistical analysis could not identify any predic-

tion of long-term outcome based on control of hyper-

lipidemia. We suspect that failure to conclude an

effect of hyperlipidemia, or its treatment, on our

patients’ long-term survival likely represents a type

II statistical error. Our current practice is to initiate

statin medications based upon the evidence

Vol. 24, No. 1, January 2010 Long-term results of eversion CEA 97

supporting a risk reduction in cardiovascular events

in the perioperative22,23 and long-term24-26 time

frames. Intensified statin regimens are encouraged

as benefit has been shown in patients with peripheral

arterial disease, but dose escalation is left to the

discretion of the primary-care physician.27,28

Restenosis is the Achilles’ heel of any vascular

intervention. Our restenosis rate was very low at

4.1% with an average follow-up of 8.86 years. In

addition, as several of the identified restenosis

events were in the time frame of 5-10 years, it is

possible that recurrence of native atherosclerotic

disease may account for some of these cases rather

than the typical biology of restenosis and myointi-

mal hyperplasia. We did not identify any patient

or anatomic factor associated with risk of restenosis

and conclude that absence of such findings suggests

a confluence of suitability of the ECEA for our

patients, diligent technique to avoid residual

disease, and the possibility that the event rate was

too low to have statistical power. The eversion tech-

nique has been shown by others to yield similarly

low long-term restenosis. Cao et al.29 reported

4-year follow-up of 1,353 patients randomized to

ECEA or standard CEA, and the ECEA cumulative

restenosis rate was 3.6% vs. 9.2% for standard

CEA. In analysis, ECEA was a negative predictor of

restenosis (HR¼ 0.3, p¼ 0.004). Their trial was crit-

icized for including both primary closure and patch

closure under the same treatment arm, but the low

rate of restenosis with ECEA was affirmed by others

who included >4 years of follow-up.9,30

Restenosis of ECEA is likely to have different

implications from standard CEA restenosis; without

the ICA suture line, ECEA restenosis may be even

more benign and less likely to produce symptoms.

Overall, recurrent stenosis is an uncommon source

of recurrent carotid symptomatology, often quoted

to be 3% or less of symptomatic carotid lesions.31,32

In examination of restenosis after ECEA, Green

et al.33 reported that recurrent stenosis at the distal

end of an ECEA was only 0.9% vs. 5% with standard

CEA. For Green et al.,33 most ECEA recurrences

developed at the proximal edge of the common

carotid eversion. We would echo their recommenda-

tion to fully expose the common carotid artery to

ensure all proximal disease is detected. Our experi-

ence with restenosis was similar to that of Green

et al.,33 with most early restenosis events occurring

in the common carotid artery (8/10 patients identi-

fied in the first 5 years of follow-up) versus the ICA

end point. Our later recurrences seem to be more

diffuse and have no predilection for location,

perhaps suggesting recurrence of atherosclerotic

disease and not typical myointimal hyperplasia.

Although Green et al.’s33 follow-up was only

1 year, the chronobiology of recurrent stenosis

suggests most of the restenosis events were captured

by their study. In an analysis of the Medline data-

base, the rate of restenosis for all CEAs was estimated

at 10% within the first year, 3% in the second year,

and 2% in the third year, suggesting that the rate of

restenosis is clearly not a linear biological process.32

As such, we believe the completeness of our duplex

follow-up is sufficient to identify patients who devel-

oped restenosis in our long-term time frame.

Carotid angioplasty and stenting (CAS) is rapidly

assuming a position in the armamentarium of

vascular specialists, inviting comparison with

ECEA or standard CEA with patch placement. Early

and mid-term CAS results have been strongly

debated, with supporters and detractors occasionally

degenerating into calls of misrepresentation.34 Prior

reports have not clarified the in-stent restenosis

rate, with a range of <5% to >20% reported.35,36

Long-term results are now emerging to demonstrate

the durability of CAS. de Donato and colleagues37

reported a 5-year restenosis rate of 6%, which

would seem to compare favorably with ECEA. We

believe that earlier reports demonstrating poor

restenosis rates may have included CAS technology

that was immature and incited exuberant intimal

damage, but in the absence of good data concerning

lowe and moderateecardiovascular risk patients

and CAS, we continue to advocate ECEA or standard

CEA technique with patch angioplasty closure for

our patients. Our experience suggests ECEA can

achieve excellent long-term results and may have

advantages over standard CEA techniques; thus, it

may be considered the ‘‘gold standard’’ to which

CAS results should be compared.

CONCLUSIONS

ECEA is a safe procedure with acceptable periopera-

tive results to address extracranial carotid disease,

produces admirable long-term results that compare

favorably with patch closure, and outperforms

primary longitudinal closure. Given our findings,

ECEA should be included among ‘‘best surgical

treatments’’ when comparison is made to CAS

results. Regardless of the technique of CEA, the

long-term results of carotid surgery will assume

greater importance as the long-term benefit of cath-

eter-based techniques to address carotid occlusive

disease has not been well defined. It is incumbent

on vascular surgeons and interventionalists to

recommend the safest proceduredone with strong

initial results and that delivers the most favorable

long-term outcomes.

98 Black et al. Annals of Vascular Surgery

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