Interposition Grafts for Difficult Carotid Artery Reconstruction: A 17-Year Experience

Article Outline

• Abstract
• Introduction
• Methods
• Results
• Discussion
• Conclusion
• Acknowledgment
• References
• Copyright

Carotid interposition grafts (CIP) for carotid artery revascularization can be a viable alternative to carotid endarterectomy (CEA) or carotid artery stenting (CAS) for complex carotid disease. This is a retrospective review of the UCLA 17-year experience with CIP for carotid reconstruction. Carotid operations performed between 1988 and 2005 revealed 41 CIP procedures in 39 patients using polytetrafluoroethylene (PTFE, n = 31) or reversed greater saphenous vein (Vein) (n = 10). Perioperative data and long-term follow-up for each conduit were statistically compared. There were no significant differences in demographics, risk factors, operative indications, complications, or 30-day perioperative deaths. There was one postoperative stroke in each group, for an overall stroke rate of 4.9% (PTFE 3.2%, Vein 10%). There was one asymptomatic occlusion and there were two high-grade restenoses in the PTFE group compared with one asymptomatic occlusion and one high-grade restenosis in the Vein group. Overall primary patency was 90% and the assisted primary patency was 97% for the PTFE group (mean follow-up 50 months), whereas primary patency was 80% (mean follow-up 30 months) in the Vein group. CIP is a safe and effective technique with excellent long-term follow-up for complex carotid reconstruction when CEA or CAS may be contraindicated.

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Introduction 

Carotid endarterectomy (CEA) has been traditionally the standard treatment choice for symptomatic and high-grade asymptomatic carotid artery stenoses. However, complex carotid reconstruction is sometimes necessary in cases of previous carotid procedures with symptomatic or asymptomatic recurrent stenosis, previous radiation exposure, aneurysms or pseudoaneurysms, tumor, or technical difficulties during primary CEA or carotid artery stenting (CAS). Few studies have addressed the utility of carotid interposition grafts (CIP) and the choice of graft material in the management of complex carotid reconstruction. The purpose of this study was to evaluate our 17-year experience at the University of California Los Angeles (UCLA) using CIP for complex carotid reconstruction and to compare the outcomes and long-term follow-up of autogenous reversed saphenous vein grafts (Vein) and prosthetic polytetrafluoroethylene (PTFE) conduits.

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Methods 

A retrospective review of all patients undergoing carotid surgery from 1988 to 2005 by the vascular surgery service at UCLA was performed. The subset of patients who underwent CIP was selected for further analysis. Patient demographics including age, gender, cardiovascular risk factors, clinical history, presentation, methods of evaluation, operative indications, intraoperative details, complications, and length of stay were recorded. All patients underwent routine follow-up duplex ultrasound evaluation of the reconstruction by our accredited vascular laboratory, and graft patency was objectively documented and defined as freedom from >60% restenosis. End points specifically analyzed were 30-day death, stroke, and other procedure-related complications and the occurrence of late stroke, death, or secondary restenosis.

The technique for interposition grafting was to fashion a graft, end to end, from the common carotid artery through the bifurcation to the normal internal carotid artery (ICA) and to resect the diseased segment of the ICA (see Fig. 1). The origin of the external carotid was preserved only when possible. The size of the PTFE graft was chosen to best fit the diameter of the native vessels. The Vein graft was obtained from the thigh and was only used when of adequate diameter and quality in a reversed fashion.

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• Fig. 1 

  The operative technique most commonly employed: end to end, from the common carotid artery through the bifurcation to the normal ICA, with resection of the diseased segment of ICA. The external carotid was preserved only when possible.

Patients were grouped according to the type of conduit used for carotid reconstruction, Vein or PTFE graft. The two groups were compared using either χ² or Student's t-test, as appropriate, to evaluate for significant differences in demographics, risk factors, indications, intraoperative details, outcomes, and graft patency. Kaplan-Meier life-table analysis was used to evaluate graft patency. p < 0.05 was considered significant for all statistical analyses.

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Results 

Overall, there were 41 interposition grafts placed in 39 patients (PTFE n = 31, Vein n = 10). Demographics and risk factors are displayed in Table I and are in the usual distribution for vascular patients. There was a significantly disproportionate percentage of male patients in the Vein group compared to the PTFE group (80% vs. 42%, p = 0.04, respectively). The only other significant difference in demographics between the two was that more patients in the PTFE group had hyperlipidemia compared with the Vein group (48% vs. 10%, p = 0.03, respectively). Operative indications are listed in Table II. The main operative indication for CIP was a previous carotid procedure, with 28 patients (PTFE n = 23, vein n = 5, total 68%) having had either one or multiple prior CEA or CAS procedures. Of those with a previous carotid procedure, nine were symptomatic (PTFE n = 8, vein n = 1, total 32%) with either ipsilateral previous strokes or transient ischemic attacks (TIAs) and 19 were asymptomatic (PTFE n = 15, vein n = 4, total 68%) with high-grade stenosis >80% by duplex criteria. There were no significant differences between symptomatic patients (39% vs. 20%, p = 0.6) and asymptomatic patients (61% vs. 80%, p = 0.6) treated with PTFE or Vein CIP, respectively.

Table I. Patient demographics and cardiovascular and operative risk factors comparing CIP using PTFE (n = 31) with Vein (n = 10) grafting

Demographics	PTFE (%)	Vein (%)	p
Male	13 (41.9%)	8 (80%)	0.04
Female	18 (58.1%)	2 (20%)	0.04
Age range (years)	29-85	51-78
Age, mean	63.6 yrs	66.2 yrs	NS
Age, median	67 yrs	67 yrs
Risk factors
Hypertension	21 (67.7%)	7 (70%)	NS
Tobacco	19 (61.3%)	7 (70%)	NS
Hyperlipidemia	15 (48.4%)	1 (10%)	0.03
Diabetes mellitus	2 (6.5%)	2 (20%)	NS
Coronary artery disease	9 (29%)	2 (20%)	NS
Previous myocardial infarction	2 (6.5%)	1 (10%)	NS
Congestive heart failure	0	0	NS
Angina	1 (3.2%)	2 (20%)	NS
CABG	3 (9.7%)	1 (10%)	NS
COPD	1 (3.2%)	1 (10%)	NS
Renal insufficiency	3 (9.7%)	0	NS
Neck radiation therapy	4 (12.9%)	1 (10%)	NS

NS, nonsignificant.

Table II. Operative indications for CIP with PTFE (n = 31) or Vein (n = 10) graft

The figures in the table refer to the number of patients with that specific indication for CIP. Note that there were multiple indications for CIP in some patients.

There were multiple indications for CIP in some patients. There were a total of five cases with prior radiation exposure as an indication for CIP (PTFE n = 4, vein n = 1). Out of the PTFE cases with prior radiation exposure, two presented with pseudoaneurysms and the other two presented with recurrent stenosis after a previous carotid procedure. The indication for Vein CIP in the radiation-exposed neck was secondary to atherosclerosis, with the attempted primary CEA leading to irreversible damage of the artery, necessitating CIP reconstruction.

Other operative indications included three carotid aneurysms (PTFE n = 1, vein n = 2), two carotid body tumors, one dissection, and one kinking and coiling of the ICA, all in the PTFE group. There were two patients with fibromuscular dysplasia, one of whom presented with recurrent stenosis after a prior carotid procedure and had a PTFE CIP performed. The other was a primary carotid operation in which fibromuscular dysplasia of the carotid was noted and a vein CIP was performed. Nine patients (PTFE n = 6, vein n = 3) had technical difficulties with CEA necessitating CIP reconstruction.

Table III lists important operative details. All patients underwent general endotracheal anesthesia and most had electroencephalographic (EEG) brain map monitoring. A greater proportion of patients in the Vein group than the PTFE group had a shunt placed based on EEG monitoring, and this approached statistical significance (40% vs. 13%, p = 0.06, respectively). The Vein group also had completion angiography performed more often compared to the PTFE group, which also approached statistical significance (40% vs. 13%, p = 0.06, respectively). The PTFE group had significantly more completion duplex ultrasound performed than the Vein group (71% vs. 20%, p = 0.004, respectively). This is standard at our institution for PTFE replacement cases. There was significantly greater estimated blood loss in the Vein group versus the PTFE group (160 vs. 71 mL, p = 0.002, respectively), although this amount was still quite negligible and did not result in any increased transfusion requirements. There were no intraoperative complications in either group.

Table III. Operative details for CIP using PTFE (n = 31) vs. Vein (n = 10)

NS, nonsignificant.

Table IV describes the postoperative complications. There were no 30-day perioperative deaths in either group. There were two postoperative strokes, one in each group; and this was not statistically significant between the two. The total 30-day stroke rate was 4.9% (PTFE 3.2%, Vein 10%). The stroke in the PTFE group occurred in a patient undergoing a primary CEA for symptomatic carotid stenosis. This case was complicated by significant kinking and coiling of the ICA, requiring resection and PTFE replacement. The patient had hemiparesis postoperatively, which had nearly resolved by discharge on postoperative day 25. The stay was complicated by development of pneumonia. The stroke in the Vein group occurred in a patient who had had two previous CEAs on the same side with symptomatic recurrent stenosis who had suffered a previous stroke with residual hemiparesis. He had intraoperative shunting performed, yet postoperatively had a worsening of his previous hemiparesis, which remained at discharge. There was one TIA in the PTFE group that resolved less than 12 hr after surgery. There were proportionately more postoperative cranial nerve palsies in the Vein group than the PTFE group, but this did not achieve statistical significance (20% vs. 12.9%, p = 0.08, respectively). In the PTFE group, three out of the four patients who had cranial nerve dysfunction had had a previous carotid operation and one of those patients also had had a prior radiation exposure of the neck. In the Vein group, neither of the two patients had received previous carotid procedures; however, one had had a previous exposure to neck irradiation. The mean length of stay was 3.4 days (range 1-25) for the PTFE group and 5.1 days (range 2-12) for the Vein group. Median length of stay was slightly longer in the Vein group than the PTFE group (4 vs. 2 days, respectively). There were no statistical differences in the mean length of stay between the two groups. Upon examining the intensive care unit (ICU) length of stay, seven out of 10 patients in the Vein group required a total ICU stay of 13 days whereas only seven out of 31 patients in the PTFE group required a total of 12 days in the ICU. Therefore, the mean length of stay in the ICU was not statistically significant between the Vein and PTFE groups (1.9 vs. 1.7 days, p = 0.09, respectively), although fewer patients in the PTFE group required ICU stay.

Table IV. Postoperative complications of CIP using PTFE (n = 31) vs. Vein (n = 10)

NS, nonsignificant.

Mean follow-up was 50 months for the PTFE group and 30 months for the Vein group. The range of follow-up was 6-128 months for the PTFE group and 2-71 months for the Vein group. In the PTFE group 29 of 31 patients (94%) and in the Vein group 10 out of 10 patients (100%) underwent postoperative duplex scanning. There was one asymptomatic occlusion in each group. The occlusion in the PTFE group was detected 17 days postoperatively, angioplastied, and stented but again reoccluded and was ligated on postoperative day 32 after it had become infected, necessitating its removal. The vein graft occlusion was detected 9 months postoperatively and left alone as the patient remained asymptomatic. There were three hemodynamically significant lesions detected, two in the PTFE group and one in the Vein group. The PTFE stenoses were detected at <1 month and 7 months postoperatively, and patients underwent successful angioplasty and stenting procedures and remained patent at last follow-up. The vein graft stenosis was detected 26 months postoperatively, and the patient elected not to have further treatment and was lost to follow-up. Figure 2 is a Kaplan-Meier graph illustrating patency for the PTFE and Vein groups. The overall primary patency for CIP grafts using PTFE was 90%, with an assisted primary patency of 97%. In the Vein group, the overall primary patency was 80%. The choice of conduit did not appear to have a significant impact on the primary patency of the CIP graft in our series (PTFE vs. Vein p = 0.24). However, there was a significant difference between the assisted primary patency of PTFE and the primary patency of Vein grafts (PTFE vs. Vein p = 0.04). There was one late death in the PTFE group, which was a patient who died 4 months after surgery from coronary artery disease, and no long-term strokes have been reported in this series to date.

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• Fig. 2 

  Kaplan-Meier graph comparing the cumulative primary patency and assisted primary patency of PTFE (n = 31) to the primary patency of Vein (n = 10) CIP grafts. There was no significant difference between the primary patency of PTFE and primary patency of Vein grafts (p = 0.24) but a significant difference between the primary assisted patency of PTFE and primary patency of Vein grafts (p = 0.04). Note that there were no patients in the Vein group who had primary assisted patency.

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Discussion 

The standard operative approach to carotid disease has been CEA, with an improvement of stroke-free survival data compared with best medical management.¹, ², ³ However, complex carotid reconstruction is sometimes necessary in cases of previous carotid procedures with symptomatic and asymptomatic recurrent stenosis, aneurysms or pseudoaneurysms, or technical difficulties during CEA, such as in a previously irradiated neck. Here, we present clear evidence for the utility of CIP in the management of complex carotid reconstruction, with long-term follow-up demonstrating excellent patency and stroke-free survival. We propose this treatment modality as a viable alternative to standard CEA or CAS when these treatment options are not feasible.

By far the most common indication for CIP in our series was a previous carotid procedure. Twenty-eight out of 41 (68%) patients had had a previous carotid procedure, with 44% of patients having had a previous primary CEA, 22% having had two prior CEAs, and 2% having had three prior CEAs. There was one patient who had had a prior CAS procedure who developed asymptomatic recurrent stenosis >80% by duplex criteria. There were no significant differences between symptomatic and asymptomatic patients treated with PTFE or Vein CIP.

Prior neck irradiation did not preclude the use of CIP as four out of the five patients with previous neck irradiation had patent grafts after an average of 20 months. However, the one patient with a PTFE CIP complicated by occlusion and infection requiring ligation and removal had previously undergone neck irradiation. It is unclear whether or not previous neck radiation would be a relative contraindication to PTFE CIP graft insertion.

In our series PTFE was the preferred choice of conduit in most of the patients, with 76% of all grafts being PTFE compared to 24% of patients in the Vein group. This most likely represents the ease of use of PTFE versus vein, without the added length of procedure and comorbidity of harvesting the greater saphenous vein from the thigh. Vein was chosen if there was any suggestion of infection, such as a mycotic aneurysm presenting as a pseudoaneurysm.⁴ There were no statistical differences in the other indications for choice of conduit. Mortality was 0% and the 30-day stroke rate was 4.9% in this series. This is greater than our primary CEA data with a stroke rate of 1.1%⁵ but comparable to the international trials on CEA.¹, ², ³ Veldenz et al.⁶ in their series of 51 PTFE CIP procedures reported a stroke rate of 1.9%, and Sise et al.⁷ in their series of 26 PTFE CIP grafts demonstrated no perioperative complications. However, the indication for performing a CIP for recurrent carotid disease was present in 68% of our cases in comparison with 57% and 36% of their cases, respectively. This may account for a higher-risk patient population with concomitantly increased risk of stroke in our series. In a combined series of PTFE interposition grafts (n = 12) and PTFE bypass grafts (n = 20) for carotid disease, Becquemin et al.⁸ showed a stroke rate of 3%, which is similar to our findings. Treiman et al.⁹ established a stroke rate of 3.5% in 57 patients with recurrent carotid stenosis following carotid resection and Vein CIP, which is also consistent with our findings. For carotid bypass grafting, variable results have been achieved with the use of either conduit, demonstrating a stroke rate (death rate) of 0-5% (0%)¹⁰, ¹¹, ¹² for PTFE and 1-9% (0.7-4.5%)¹⁰, ¹³, ¹⁴ for Vein.

Recurrent carotid disease patients represent a technically more challenging group and have associated higher risk for stroke and mortality. A review of the literature demonstrates that within the redo carotid surgery group the stroke and mortality data range 0-5.3% and 0-1.4%, respectively, and cranial nerve dysfunction, 1-17%.¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²² In these series, redo CEA is primarily the main treatment modality for treating recurrent carotid disease, with carotid bypass grafting and CIP being utilized in a minority of cases. When compared as a whole, our stroke (4.9%), mortality (0%), and complication rates, including cranial nerve dysfunction rate (15%), are within the range of these other published series for the “standard” treatment of recurrent carotid disease.

Our length of stay was significantly longer than our previously published comparable data on primary CEA, with most patients staying between 3.8 and 1.6 days, for the under 80-year-old group. However, they spent an equivalent number of days in the ICU (1.8 vs. 1.7 days in the under 80-year-old group).⁵ The longer stay in this series was a direct result of a patient in each group having had a stroke. In the PTFE group, this patient stayed 25 days, and in the Vein group this patient stayed 12 days. This significantly contributed to the overall increase in mean length of stay for the group; however, median length of stay (2 days for the PTFE group vs. 4 days for the Vein group) was more comparable between each series. Notwithstanding, a slightly longer median stay can be attributed to an increased number of minor complications, such as a resolving cranial nerve or vocal cord palsy or a nonoperatively managed small hematoma, following a more difficult operative dissection in this group of patients.

Follow-up data demonstrated an overall PTFE CIP primary patency of 90% and an assisted primary patency of 97% over an average of 50 months. The primary patency of PTFE grafts was not significantly different from our Vein primary patency of 80% over a mean of 30 months (p = 0.24). However, our PTFE group assisted patency was significantly better than our Vein primary patency (p = 0.04). This most likely represents the fact that the one patient with a restenosis in the Vein group elected not to have any further treatment and in effect eliminated an assisted primary patency Vein group for comparison. There have been no late strokes or deaths recorded in our series to date. To our knowledge, this is the longest period of follow-up for CIP grafting procedures for the carotid artery. Our data are consistent with those of other authors demonstrating good overall long-term patency using CIP grafts. Veldenz et al.⁶ illustrated a long-term patency and stroke-free survival rate at 2 years that exceeded 96%, and Sise et al.⁷ demonstrated a survival and stenosis-free rate of 89% at 39 months in their PTFE CIP series. Becquemin et al.⁸ showed 89% primary patency of PTFE CIP and bypass grafts at 4 years in their series. Our Vein CIP patency is similar to the 93% overall graft patency after 35 months established by Treiman et al.⁹ for a larger Vein CIP series. After carotid bypass grafting, the range for stenosis-free survival was 83% at 3 years using Vein¹⁴ and 95% at 3 years using PTFE.¹¹

Overall, when looking at recurrent carotid operations, the stroke-free survival rates vary from 90% to 93.6% at 5 years¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²¹, ²² and freedom from restenosis rates vary from 88.2% to 96% at 5 years.¹⁷, ¹⁸, ¹⁹, ²¹, ²² This suggests that CIP, even when used for recurrent carotid disease, has comparable long-term stroke-free and restenosis -free survival rates compared with the standard operative approach of CEA or redo CEA.

Based on these data and with due consideration of its limitation in size and its retrospective nature, we can conclude that CIP is an excellent alternative when CEA or CAS is not feasible and that in patients with recurrent carotid disease in whom redo CEA is associated with a high incidence of restenosis due to intimal hyperplasia, it is a safe and possibly preferential option. In addition, when CIP is determined to be necessary, PTFE may be the choice of conduit with the advantage of ease of use, decreased morbidity of no harvest site from the thigh, and excellent comparable long-term patency compared to standard CEA, redo CEA, or autogenous vein CIP reconstruction. The utilization of vein CIP may be reserved for specific indications such as an obviously infected field or possibly an irradiated neck. Further prospective studies, with long-term follow-up, are necessary to determine the best choice of conduit in these difficult cases.

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Conclusion 

The role of CIP grafting is for recurrent carotid surgery, aneurysm, tumor, and other various complex carotid reconstructions where CEA or CAS cannot be used or is contraindicated. We have shown clearly that CIP grafting is an addition to the armamentarium of vascular surgeons that is both safe and effective in the short term with excellent long-term stroke survival and restenosis-free survival data on follow-up.

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The authors thank Robert Lohman, MD, for his help with Figure 1.

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