A meta-analysis of combined endarterectomy and proximal balloon angioplasty for tandem disease of the arch vessels and carotid bifurcation

• Published in: Journal of vascular surgery 2011-08, Vol.54 (2), p.534-540
• Main Authors: Sfyroeras, Giorgos S., MD, PhD, Karathanos, Christos, MD, Antoniou, George A., MD, Saleptsis, Vassileios, MD, Giannoukas, Athanasios D., MD, MSc, PhD, FEBVS
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Angioplasty, Balloon - adverse effects; Angioplasty, Balloon - instrumentation; Angioplasty, Balloon - mortality; Arterial Occlusive Diseases - complications; Arterial Occlusive Diseases - mortality; Arterial Occlusive Diseases - therapy; Biological and medical sciences; Brachiocephalic Trunk; Carotid Artery, Common; Carotid Artery, Internal - surgery; Carotid Stenosis - complications; Carotid Stenosis - mortality; Carotid Stenosis - surgery; Carotid Stenosis - therapy; Combined Modality Therapy; Constriction, Pathologic; Endarterectomy, Carotid - adverse effects; Endarterectomy, Carotid - mortality; Female; Humans; Male; Medical sciences; Middle Aged; Neurology; Recurrence; Risk Assessment; Risk Factors; Stents; Stroke - etiology; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Time Factors; Treatment Outcome; Vascular diseases and vascular malformations of the nervous system; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2011.04.022

Objective High grade stenoses of both the innominate (IA) or common carotid artery (CCA) and the carotid bifurcation are rare and represent a therapeutic dilemma for the treating physician. A hybrid procedure with concomitant carotid endarterectomy (CEA) and retrograde angioplasty has been proposed as a less invasive treatment option. The aim of this study is to review the existing literature on such hybrid procedures. Methods An electronic search of the pertinent English literature was undertaken. A meta-analysis of all studies reporting on simultaneous carotid endarterectomy and retrograde angioplasty for the treatment of tandem internal carotid and proximal common carotid or innominate artery lesions was performed. Results Thirteen studies, including 133 patients were identified. Sixty-eight percent of the patients were male, 83% symptomatic. Proximal lesions were located in ipsilateral CCA in 85 cases and in IA in 48 cases. Reported technical success of the procedure was 97%. In 79 of the 129 successful operations, a stent was implanted, while the remaining 50 patients underwent simple balloon angioplasty. Thirty-day mortality and stroke rate were 0.7% and 1.5%, respectively. Combined 30-day mortality and stroke rate was 1.5%. During a mean follow-up of 12 to 36 months, five patients presented symptoms of cerebral ischemia and 17 died. Ten patients developed restenosis of the proximal lesion, (4 symptomatic, 7 in cases without stent) and 2 restenoses of the endarterectomy (all asymptomatic). Restenosis was treated in 7 cases (4 repeat angioplasty, 3 bypass grafts). Conclusions This meta-analysis reports the largest collection of patients having undergone hybrid treatment of tandem disease of the arch vessels and carotid bifurcation. Results from this study show that the combined stroke and death rate with this approach is equal to or better than that for isolated endarterectomy. When possible, balloon angioplasty with stenting of the proximal component of this disease should be pursued to avoid restenosis.