To date, the CEA studies have provided highly
controversial results in terms of post-CEA closure
techniques. The general view is that the patch
closure method minimizes the risk of perioperative
and long-term stroke and restenosis, compared to the
primary closure method; however, the existence of controversial results requires more studies to support
these findings.[
7,
8,
16-
18] There is still no consensus
among the surgeons about the closure technique
and, therefore, each surgeon decides on the closure
technique based on his or her own experience. In the
present study, we found no statistically significant
difference in the perioperative results, except for
hematoma, between the two groups.
In previous studies, the effects of closure
techniques in CEA on complications developed after
surgery were studied. In a meta-analysis conducted
in 2,157 patients, the patch closure technique was
associated with a significant reduction in perioperative
ipsilateral stroke and ICA thrombosis within
30 days.[19] Besides, in the long-term, late ipsilateral
stroke and ICA restenosis rates reduced in patients
undergoing patch closure technique. However, there
was no significant difference between the primary
and patch closure techniques in terms of perioperative
and stroke-related mortality. Similarly, another
study reported lower restenosis rates compared to
primary closure after patch procedure.[20] In addition,
patients undergoing patch closure had a lower rate
of restenosis within two years after CEA.[21] In this
study, restenosis rates were slightly higher in Group 2,
although not statistically significant. This result can
be attributed to the patient selection criteria used in
the study.
In the first Cochrane review published in 2009 and
which was updated in 2011, there was no significant
difference between the two closure methods in the
perioperative period; however, the patch closure
method was reported to reduce stroke and restenosis
rates in the long-term.[7,<22>] In a study in which the
patch closure method was riskier than primary closure
was emphasized, patients who received patch closure
(12.9%) had an incidence of recurrent CAS compared
to those with primary closure (1.7%).[23] In this study,
the authors used venous patch material and, in case of
using a saphenous vein, it did not show any superiority
over primary closure in the long-term of five years.
However, many other studies suggested that there
was no significant difference between the two closure
methods. In one of these studies, neither methods
affected the occlusion or stroke rates.[23]
On the other hand, the primary closure method
has several advantages compared to the patch closure
method, including low risk of infection, fewer
complications, and shorter operation and arteriotomy time.[13,14,18] Previous retrospective studies have shown
that closure techniques do not affect perioperative
and long-term postoperative results. In a study
conducted using the American College of Surgeons
(ACS) NSQIP database, closure techniques for CEA
were not found to be associated with complications.
On the contrary, one or more high-risk features
such as preoperative stroke, age above 80 years,
and active smoking were found to be predictors of
30-day postoperative stroke or death after CEA in
patients having these risks.[14] In a very recent study
conducted in South Korea, no significant difference
in restenosis rates was observed in the perioperative
period and long-term after patch and primary closure
techniques in 435 patients.[24] In another study,
there was no statistically significant difference in
the restenosis rate in the mid-term between the
patch closure and primary closure techniques.[25]
This finding is also consistent with our study
results. Some urgent CEAs were performed with
primary closure for short cross-clamp time of carotid
arteries.[26] Also, in our study, primary closure
technique decreased clamping time, although there
was no significant difference in the stroke rates in
early- and mid-term.
Doppler ultrasonography can be useful in
following patients after surgery for restenosis and
preoperative risks.[27] In our study, we followed
patients with Doppler ultrasonography after
surgery. If there was stenosis over 50% on Doppler
ultrasonography, we used CTA for these patients.
Furthermore, although combined antiaggregant
and anticoagulant therapy was administered in a
study,[28] in our study, medical treatment was chosen
for each case individually.
Nonetheless, there are some limitations to this
study. Its retrospective and single-center design are
the main limitations which preclude the generalization
of the results. In addition, common opinions in
choosing a closure technique for surgeons working
in a single center may lead to a biased selection.
Also, as perioperative data were not included in our
study, postoperative results were further elaborated.
Additionally, the duration of follow-up was relatively
short (one year) and, thus, long-term follow-up is
required for further evaluation and recommendation.
Also, if the ICA diameter was below 5 mm, primary
closure technique was not preferred, indicating a
significant difference in the anatomical structure
of the ICA between the two groups. We believe that further large-scale, long-term, prospective,
randomized studies would provide more robust data
about the primary closure technique.
In conclusion, there was no significant difference
between the primary and patch closure techniques
in terms of AMI, short- and long-term stroke,
transient ischemic attack, and long-term restenosis
and mortality rates. Our study results suggest that
the application of patch or primary closure techniques
during CEA has no significant superiority to each
other in the early- and mid-term. In eligible cases and
in whom the ICA diameter is over 5 mm, primary
closure can be performed safely.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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