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Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 83-86

An Institutional Experience of Modified Eversion Endarterectomy in the Management of Carotid Artery Stenosis

Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India

Date of Web Publication25-Jul-2016

Correspondence Address:
Dr. Kamran Ali Khan
Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0820.186720

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Background: Carotid endarterectomy (CEA) using eversion technique has been used by vascular surgeons across the world. A simpler technique, modified eversion endarterectomy (MEE) is emerging as a promising option. Advantages are shorter clamping time, less neurological complications, and avoidance of prosthetic patch plasty. Selective shunting can be done whenever required. In the climate of carotid artery stenting versus CEA debate, one would consider this method to reduce the morbidity of CEA.
Materials and Methods: This is a retrospective analysis of patients undergoing CEA at a single institution by four vascular surgeons over a period of 2½ years (January 2012–June 2014). Data were collected from computerized medical records and various parameters analyzed. Forty patients underwent MEE during the given period. The majority were symptomatic 34 (85%).
Results: One patient (2.5%) required conversion to conventional endarterectomy with patch plasty because of the long length of the plaque. One patient (2.5%) had lateralizing transient ischemic attack (TIA) in the postoperative period. Two patients had hematoma of which one was returned to operating theater for evacuation. Seven patients underwent MEE along with coronary artery bypass grafting with uneventful recovery. Selective shunting was done for four patients (10%) who had a contralateral occlusive disease or poor back bleed from an internal carotid artery (ICA) on table. Average ICA cross-clamping time was 13 min. None of the patients had cerebrovascular accident/TIA in the follow-up period.
Conclusions: MEE is a simpler and easier technique to perform with comparable results when compared with other conventional techniques. MEE, in our assumption, will be the technique of choice in the future for open CEA; however, larger studies with longer follow-up are required before final validation of this technique.

Keywords: Carotid artery stenting, carotid endarterectomy, cerebrovascular accident, internal carotid artery, modified eversion endarterectomy, transient ischemic attacks

How to cite this article:
Khan KA, Bedi VS, Prabhu M, Agarwal S, Yadav A, Satwik A. An Institutional Experience of Modified Eversion Endarterectomy in the Management of Carotid Artery Stenosis. Indian J Vasc Endovasc Surg 2016;3:83-6

How to cite this URL:
Khan KA, Bedi VS, Prabhu M, Agarwal S, Yadav A, Satwik A. An Institutional Experience of Modified Eversion Endarterectomy in the Management of Carotid Artery Stenosis. Indian J Vasc Endovasc Surg [serial online] 2016 [cited 2022 Sep 25];3:83-6. Available from:

  Introduction Top

Cerebrovascular disease is the second leading cause of death worldwide accounting for 9.5% of all deaths. About 80% of the strokes are ischemic, and carotid disease is the cause in 40% of these patients.[1]

Since 1954 when Eastcott et al.[2] had first introduced carotid endarterectomy (CEA) as a treatment for carotid artery stenosis, the technique has undergone many modifications. Conventional endarterectomy involves longitudinal incision from common carotid artery (CCA) to distal end of internal carotid artery (ICA) where healthy intima is seen. There is very good visualization of the end point of the plaque, which is the major advantage of this technique. To prevent restenosis, polytetrafluoroethylene (PTFE)/vein patch is used to repair the arteriotomy.

Modified eversion endarterectomy (MEE) is a merge of the two techniques-conventional and eversion endarterectomy.[3],[4] The simplicity of the technique, its ability to achieve the end point with a very short clamping time and provision to primarily close the arteriotomy without the need of a patch are the Achilles heel of this procedure. One would make use of the advantages of both conventional and eversion endarterectomy using this technique. Moreover, it can be converted easily into a conventional repair if, at any time, the surgeon feels that the arteriotomy needs to be extended into the ICA. Perioperative rates of stroke are comparable with other techniques, however, assessment of rates of restenosis will require longer term follow-up.

  Materials and Methods Top

From January 2012 to June 2014, forty patients underwent CEA by modified eversion technique, being operated by four qualified vascular surgeons from a single institute. This is a retrospective analysis of the data from the medical records of these patients. Data regarding patient demographics, comorbidities, presenting symptoms, and severity of stenosis were obtained. Patient demographics are listed in [Table 1]. Most of the patients had undergone carotid Doppler ultrasound followed by computed tomography/magnetic resonance (CT/MR) angiography or digital subtraction angiography (DSA) when diagnosed at the time of coronary angiography. The preliminary diagnosis was done with color Doppler followed by CT or MR angiography in 36 patients (90%). Four patients underwent conventional DSA at the time of coronary angiography (10%).
Table 1: Patient demographics

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The various clinical presentations are categorized and depicted in [Figure 1]. Seventeen patients (42.5%) presented with stroke, 13 (32.5%) had lateralizing transient ischemic attack (TIA), and 4 (10%) had Amaurosis fugax. Six patients (15%) were asymptomatic. Three patients (7.5%) had occluded contralateral internal carotid arteries. Three patients (7.5%) had recurrent disease with a history of prior carotid surgery. Seven patients (17.5%) underwent coronary artery bypass grafting (CABG) along with MEE.
Figure 1: Clinical presentation of patients with carotid artery disease. TIA: Transient ischemic attack, CVA: Cerebrovascular accident

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Operative notes were analyzed regarding technique used, ICA clamp time, use of shunt, and the rate of conversion to the conventional technique. Half of these patients were operated under general anesthesia, while the remaining halves were operated in deep cervical block, and were conscious throughout the procedure. The intraoperative parameters are displayed in [Table 2]. Decision to use the shunt was based on surgeon's intraoperative assessment of the ICA back bleed and presence of contralateral ICA occlusion.
Table 2: Intraoperative parameters

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Postoperative complications such as stroke, TIAs, myocardial infarction, bleeding or hematoma, and cranial nerve injury were documented.

Patients were positioned with their necks extende (roll kept behind the scapula) and face turned to the opposite side. Pinna of the ear was exposed in the operative field while draping the patient. Arterial line insertion was done for pressure monitoring. Oblique incision was made along the anterior border of sternocleidomastoid muscle. Platysma and deep cervical fascia were opened along the line of incision. Carotid sheath was incised carefully preserving the ansa cervicalis. The common carotid, external carotid, and internal carotid arteries were gently dissected with minimal handling and controlled with loops. Intravenous heparin (80 units/kg body weight) was given before arterial clamping. ICA, CCA, and external carotid artery (ECA) were clamped in order of sequence. This was followed by a longitudinal arteriotomy over the carotid bulb (approximately 4 cm in length). If there was poor back bleed from the ICA (or contralateral occlusion), then shunting of the artery was done using Argyle shunt. With Watson and Cheyne dissector, a plane was developed and the plaque lifted and divided proximally. The lifted plaque was dissected off from the ECA and then along the ICA. A downward tug was given to the plaque while dissecting it from the ICA to facilitate the endarterectomy. The plaque was lifted till normal healthy intima was visualized, and smooth feathering of the plaque was noted. Loose circular fibers within the artery were removed by gentle technique. If distal end point was not visualized clearly, then the procedure was converted to conventional endarterectomy by extending the arteriotomy into the ICA. Heparin saline flushing was done to remove the residual loose debris. Using a 6-0/7-0 Prolene monofilament suture, the arteriotomy closure was done with a continuous running suture. De-airing was done followed by sequential release of the clamps from the ECA, CCA, and ICA. Once, flow in the ICA was re-established, the wound was closed over a suction drain.

  Results Top

Three patients (7.5%) had 70–79% stenosis; sixteen patients (40%) were diagnosed with 80–89% stenosis, while the remaining 21 patients (52.5%) had 90–99% disease in the carotids. Majority of the patients were symptomatic (85%). The average ICA clamp time was 13 min (8 min–19 min). Four patients (10%) underwent shunting during the procedure. Two patients required minimal extension of the incision over the ICA for a distance of 1 cm to remove the residual debris (as the plaque was friable in one case and it was densely adherent to the wall in the second case), however, the ICA was closed primarily. One patient required conversion to conventional endarterectomy with PTFE patch plasty in view of the long length of the plaque.

Postoperative complications are tabulated and shown in [Table 3]. One patient had TIA (2.5%) which recovered spontaneously and CT Brain did not show any new infarcts. One patient had significant neck bleeding with expanding hematoma and was re-explored in the operating room, but no actively bleeding vessel could be identified and generalized diffuse oozing from the raw surfaces was noticed. He was given postoperative compression dressing and recovered well. Another patient developed a wound hematoma but was managed conservatively and responded well.
Table 3: Postoperative complications (after modified eversion endarterectomy)

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The mean follow-up was 10 months (minimum 4 weeks and maximum 2 years). Patients were clinically followed up and none of the patients developed stroke/TIA. There was no perioperative mortality.

  Discussion Top

Carotid artery endarterectomy plays a pivotal role in the prevention of stroke. The two commonly used techniques-standard conventional endarterectomy with or without patch plasty and eversion endarterectomy have been carried out by many surgeons throughout the world. The main issues to address in this surgery are the type of anesthesia, ICA clamping time, complexity of the procedure (patch plasty or reanastomosis to CCA after dividing the ICA) and various methods employed to reduce postoperative restenosis.

The technique of eversion endarterectomy was described by De Bakey et al. in 1959 which was later modified by Etheredge.[5],[6] His description involved transaction of the CCA at its bifurcation, followed by eversion of both ICA and ECA and reanastomosis them after clearing the plaque. However, the eversion technique was further modified by Kasprzak and Raithel in 1989 in the form of a linear incision over the bulbous part of the carotid artery and ICA.[7] The rate of restenosis was less because of its autogenous nature of repair. However, few technical difficulties were encountered like usage of shunt and visualizing the distal end point.

CEA has undergone many modifications since its description. Comparison between the two techniques-conventional endarterectomy and eversion endarterectomy showed no statistically significant differences in outcome. However, higher perioperative complications were seen in the eversion technique and higher incidence of perioperative stroke was noted in the conventional technique.[8],[9],[10]

To reduce the morbidity and mortality during the procedure, one can use the MEE technique which is a sandwich between the conventional and eversion technique. This technique was first described by Carmichael in 1980 in Archives of surgery.[11] 467 carotid endarterectomies done during a 12 years period were evaluated. Cross-clamping time was 10.5 min on an average, while it exceeded to 15 min whenever shunting was used.

In the recent past, Tan et al.[4] published a series of 99 patients, with a conversion to conventional patch plasty in only five patients (5.1%). The clamping time was 29.2 min in the MEE group and 52.2 min in the conventional patch plasty group. There was no incidence of peri-operative stroke in the MEE group, while it was 1.4% in the conventional patch plasty group.

Larger series of 221 patients was published by Kumar et al.[3] in 2013 in Annals of Vascular Surgery. They reported their postoperative complications of cerebrovascular accident, TIA and MI (myocardial infarction) in 1%, 2%, and 1% patients, respectively. Thirty-day mortality was reported to be 1%. Average cross-clamping time was 12.8 min. The shunt was used in 13% of patients who were found to have either ipsilateral cerebral infarction or contralateral occlusive disease.

MEE has the advantages of both conventional and eversion endarterectomy. It is:

  • Safe and effective
  • Possible under regional anesthesia/general anesthesia
  • Brief clamp time of about 8–13 min with selective shunting
  • Plaque extraction through a linear incision confined to the bulb
  • Allows primary closure
  • Completely autogenous repair, No patch required
  • Permits easy conversion to traditional patch closure for technical defects
  • Avoids the uncomfortable retraction of the mandible and upper end of the incision – an essential maneuver for meticulous closure of the longitudinal arteriotomy
  • Lesser incidence of nerve injury
  • Closure-technically easier and quicker
  • Overall complication rate, re-stenosis rate, and perioperative stroke/mortality are comparable to standard techniques.

The disadvantage with this technique is while removing long plaques with distal endpoints. Conversion is required when the plaque extends for more than 2.5 cm into the ICA where visualizing the distal end point becomes difficult. Large volume series like NASCET and Institutional series from Massachusetts General Hospital had a perioperative stroke and death rate of 1.4%.[12],[13] Our stroke and death rate was 0% which may be due to the smaller sample size studied.

The mean ICA clamping time is 13 min which is the Achilles' heel of the MEE technique. Reducing the clamp time will definitely reduce the morbidity and mortality associated with the procedure. The learning curve depends on the ability to achieve the end point– by removing the plaque completely without residual debris. Whenever there are residual debris one can extend the incision 5–10 mm into the ICA and remove them. When still there is a residual flap, one should extend the arteriotomy liberally and do the conventional patch repair.

We have used shunt selectively in 4 cases when contralateral ICA occlusion has been present or poor ICA back bleed has been noted on Table. There are two schools of thought those who always use the shunt believe that stroke is caused by ICA clamping and ischemia while those who never use the shunt believe that cerebral event is due to embolization rather than ischemia.[14],[15] There is no clear consensus about the need for shunting because of similar stroke rates of <3% in both groups.[16],[17],[18] However, we advocate the practice of selective shunting.

Combined procedure of MEE along with CABG is an advantageous technique because of the shorter operating time, smaller length of incision, reduced bleeding complications, and fewer fluctuations in blood pressure. This combination of technique has not being described in the literature.

  Conclusions Top

After analyzing our series we were able to understand that MEE is a simple technique which is easier to perform and has a shorter learning curve. Since our incision pertains to the bulbous part of the ICA only, there should be lesser chances of re-stenosis. However, long-term follow-up is required before final conclusions can be made in this regard. Shorter clamping time and selective shunting are the major advantages. MEE along with CABG has less morbidity and mortality. MEE will be the technique of choice in the future, but further studies with larger sample size and longer follow-up are required to validate this technique.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Eskandari MK, editor. Modern Trends in Vascular Surgery: Coronary Artery Disease. Shelton, Connecticut: Peoples Medical Publishing House – USA; 2010.  Back to cited text no. 1
Eastcott HH, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954;267:994-6.  Back to cited text no. 2
Kumar S, Lombardi JV, Alexander JB, Carabasi RA, Carpenter JP, Trani JL. Modified eversion carotid endarterectomy. Ann Vasc Surg 2013;27:178-85.  Back to cited text no. 3
Tan TW, Weyman AK, Barkhordarian S, Patterson RB. Single center experience with modified eversion carotid endarterectomy. Ann Vasc Surg 2011;25:87-93.  Back to cited text no. 4
De Bakey ME, Crawford ES, Cooley DA, Morris GC Jr. Surgical considerations of occlusive disease of innominate, carotid, subclavian, and vertebral arteries. Ann Surg 1959;149:690-710.  Back to cited text no. 5
Etheredge SN. A simple technic for carotid endarterectomy. Am J Surg 1970;120:275-8.  Back to cited text no. 6
Kasprzak PM, Raithel D. Eversion carotid endarterectomy. Technique and early results. J Cardiovasc Surg 1989;30:495.  Back to cited text no. 7
Cao PG, de Rango P, Zannetti S, Giordano G, Ricci S, Celani MG. Eversion versus conventional carotid endarterectomy for preventing stroke. Cochrane Database Syst Rev 2001;(1):CD001921.  Back to cited text no. 8
Cao P, Giordano G, De Rango P, Caporali S, Lenti M, Ricci S, et al. Eversion versus conventional carotid endarterectomy: A prospective study. Eur J Vasc Endovasc Surg 1997;14:96-104.  Back to cited text no. 9
Cao P, Giordano G, De Rango P, Zannetti S, Chiesa R, Coppi G, et al. Eversion versus conventional carotid endarterectomy: Late results of a prospective multicenter randomized trial. J Vasc Surg 2000;31(1 Pt 1):19-30.  Back to cited text no. 10
Carmichael JD. Carotid surgery in the community hospital: 467 consecutive operations. Arch Surg 1980;115:937-9.  Back to cited text no. 11
North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53.  Back to cited text no. 12
LaMuraglia GM, Brewster DC, Moncure AC, Dorer DJ, Stoner MC, Trehan SK, et al. Carotid endarterectomy at the millennium: What interventional therapy must match. Ann Surg 2004;240:535-44.  Back to cited text no. 13
McKinsey JF, Desai TR, Bassiouny HS, Piano G, Spire JP, Zarins CK, et al. Mechanisms of neurologic deficits and mortality with carotid endarterectomy. Arch Surg 1996;131:526-31.  Back to cited text no. 14
McDowell HA Jr., Gross GM, Halsey JH. Carotid endarterectomy monitored with transcranial Doppler. Ann Surg 1992;215:514-8.  Back to cited text no. 15
Halsey JH Jr. Risks and benefits of shunting in carotid endarterectomy. The international transcranial Doppler collaborators. Stroke 1992;23:1583-7.  Back to cited text no. 16
Hertzer NR, Beven EG. A retrospective comparison of the use of shunts during carotid endarterectomy. Surg Gynecol Obstet 1980;151:81-4.  Back to cited text no. 17
Gumerlock MK, Neuwelt EA. Carotid endarterectomy: To shunt or not to shunt. Stroke 1988;19:1485-90.  Back to cited text no. 18


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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