Primary closure, routine patching, and eversion endarterectomy: what is the current state of the literature supporting use of these techniques?

Our objective in this article was to review the most recent literature on the status of carotid patching or primary carotid closure following carotid endarterectomy; to determine the best patch material if needed; and to clarify the place of eversion carotid endarterectomy in management of carotid artery atherosclerosis. In order to accomplish this, a literature review was performed of the Ovid, PubMed and MedLine databases using appropriate search terms. An evidence-based approach was taken; with all articles graded using the Scottish Intercollegiate Guidelines Network system (levels of evidence 1 to 5) and recommendations were made using an A to D system. Most weight was given to well-conducted, adequately powered, randomized control trials. After review of the literature, we were able to make the following Grade A recommendation: carotid patching is superior to primary closure, resulting in fewer postoperative strokes and a lower incidence of restenosis in most surgeons' hands. However, it was also concluded that, based on review of the literature, that the choice of patch material in 2007 has little impact; eversion carotid endarterectomy (CEA) and conventional patch CEA have equivalent postoperative morbidity and similar incidences of long-term restenosis. In conclusion, the technique of CEA continues to evolve, but in most reported series, immediate and long-term outcomes are excellent. A variety of technical approaches are acceptable, but it appears that carotid patching remains superior to primary closure.