Clinical Research Double Eversion Carotid Endarterectomy of Tandem Carotid Lesions Yannick Georg, Emmanouil Psathas, Faris Alomran, Julien Gaudric, Laurent Chiche, and Fabien Koskas, Paris, France
Background: We describe an original method to treat tandem lesions of the internal carotid artery (ICA) and the common carotid artery (CCA). In this manuscript, we describe a ‘‘double eversion carotid endarterectomy’’ technique (DECE) and report our results. Methods: A retrospective review in the medical records of patients that underwent DECE over a 15-year period was performed. Patient characteristics, operative details, preoperative imaging and lesion characteristics, perioperative outcomes, and follow-up data were documented and analyzed. Patients with ostial and mediastinal lesions were excluded from our study. Operations were divided into 2 categories: ‘‘planned,’’ when the lesions were identified during preoperative imaging, and ‘‘necessary’’ when performed for secondary defects of the CCA detected intraoperatively. Results: Between 1996 and 2011, a total of 15 patients with 17 tandem lesions underwent DECE. The mean age was 74.3 years. The mean degree of stenosis was 76.3% for the ICA and 61.5% for the CCA, with the majority of the lesions being asymptomatic (12/17). All procedures were performed under general anesthesia, and in 1 case an intraluminal shunt was used. The mean operative time was 83.4 min, with a mean primary clamping time of 29.2 min. In cases of secondary lesions, the mean reclamping time was 16.2 min. There was no mortality or major neurologic event within 30 days postoperatively. Postoperative complications included 2 major cardiac events and 1 case of cranial nerve XII injury that resolved during follow-up. There were no deaths or neurologic events during a mean follow-up of 27.5 months (range: 1e188 months). One patient required a reintervention after 5 years because of restenosis of the ICA. Conclusion: DECE is an alternative surgical technique for select tandem, nonostial carotid lesions. In addition, DECE can be performed as a ‘‘bailout’’ procedure for secondary CCA defects during conventional eversion carotid endarterectomy.
INTRODUCTION Significant combined tandem lesions of both the common carotid artery (CCA) and the internal carotid artery (ICA) are present in 10 min according to our surgical experience. When shunting is considered necessary, both anastomoses are performed around the shunt, leaving a few stiches before shunt removal in order to minimize cerebral ischemia.
RESULTS Seventeen tandem carotid lesions (6 on left and 11 on the right side) in 15 patients were treated using the DECE technique during the study period. The mean age at operation was 74.3 years (range: 42e84).
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Double eversion carotid endarterectomy 3
The primary risk factors included hypertension (70.6%), smoking (53%), hyperlipidemia (58.8%), coronary artery disease (53%), diabetes (5.9%) and chronic obstructive pulmonary disease (COPD) in 35.3% of cases. Six patients (35.3%) in this cohort were considered to have symptomatic disease, defined either as previous ipsilateral transient ischemic attack (TIA) or stroke. (Table I). Twelve (70.6%) and 2 (11.7%) patients underwent preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans, respectively. Duplex ultrasonography was the only preoperative imaging in 3 (17.6%) patients because of the impossibility to achieve a CT or MRI scan. The mean degree of ICA stenosis was 76.3% (range: 50e99%). We documented 13 cases of planned operations and 4 necessary procedures. In planned cases, the mean degree of CCA stenosis was 61.5% (range: 40e 95%). In necessary operations, CCA exploration with the DECE technique was performed for remaining defects in completion biplanar angiography. These were defined either as a CCA dissection or as a remaining CCA intimal tear. The mean operative time was 83.4 min (range: 63e155 min), with a mean clamping time of 29.2 min (range: 27e56 min). In cases of secondary lesions, the mean reclamping time was 16.2 min (range: 10e 44 min). In our institution, we follow a selective shunting policy. Criteria for shunting in our practice include recent TIA or stroke, contralateral ICA occlusion, and nonpulsatile ICA backflow intraoperatively. Shunt placement was considered necessary in 1 patient in this series (6.7%). Lesion characteristics and operative details are summarized in Table II. There were no strokes, TIAs, or deaths at 30 days. We documented 2 postoperative cardiac events. One was defined as a minor myocardial infarction, with elevated ST and troponin levels on
Fig. 1. Steps of the double eversion technique. (A) Eversion endarterectomy of the internal carotid artery (ICA) is performed first. (B) A circumferential dissection plane in the common carotid artery (CCA) is created with a spatula. (C and D) After placement of a second safety clamp in the CCA, the dissection plane is advanced proximally using a spatula or a Vollmar ring stripper (Aesculap, San Jose, CA). (E) The safety clamp is removed and the CCA is sharply sectioned using Potts scissors at this very level. (F) The endarterectomized cylinder is grasped with a mosquito clamp through the bulbar incision and the CCA is everted using gentle traction. (G) After removal of the plaque, the CCA is inverted and reset in the correct anatomic position. (H) After reimplantation of the ICA in the bulb and distal declamping, the CCA is anastomosed between clamps.
4 Georg et al.
Annals of Vascular Surgery
Table I. Comorbidities and main risk factors Comorbidity or risk factor
n (%)
Symptomatic (ipsilateral TIA or stroke) Hypertension Diabetes Smoking Hyperlipidemia CAD COPD
6 12 1 9 10 9 6
(35.3) (70.6) (5.9) (53) (58.8) (53) (35.3)
CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; TIA, transient ischemic attack.
postoperative day 2. The second was a nonfatal cardiac arrest during reintubation of a patient with an evolving postoperative hematoma that caused acute respiratory distress and required emergent reexploration. The same patient had aspiration pneumonia after reintubation that required prolonged ventilation. There was 1 case of cranial nerve XII palsy, which resolved completely on follow-up. All patients were followed up postoperatively with duplex ultrasonographic studies at regular intervals. In cases of suspected restenosis, CT angiography or conventional angiography was performed. The mean follow-up period was 27.5 months (range: 1e166 months). There were no deaths or major neurologic events during followup. We documented 1 asymptomatic restenosis of the ICA (>50% reduction of the vessel lumen diameter) after 5 years. This case required reintervention using patch repair; however, the same patient developed critical ipsilateral stenosis of the common trunk and the ostium of the CCA 6 years later. This was treated with carotidecarotid bypass with a polytetrafluoroethylene graft. The patient remains well 11 years after the first operation.
DISCUSSION The natural history of tandem carotid lesions and the contribution of CCA lesions to cerebrovascular ischemic events are not well defined. Treatment options for tandem ostial CCA and ICA lesions have been described and recently debated in the literature, with open, endovascular, and hybrid techniques showing satisfactory short- and long-term results.2,3,16 However, tandem nonostial lesions of the CCA and ICA have received less attention. Management mostly depends upon the location and length of the lesion of the CCA and essentially upon surgical accessibility to the proximal, nondiseased segment of the CCA. In most cases, access to the proximal CCA can be facilitated by extension
Table II. Lesion characteristics and operative details Perioperative parameter
n (% or range)
Planned operations, n (%) Necessary operations, n (%) Shunt placement, n (%) Mean % ICA stenosis (range) Mean % CCA stenosisa (range) Operative time, min (range) Clamping time, min (range) Re-clamping time, minb (range)
13 4 1 76.30 61.50 83.4 29.2 16.2
(76.5) (23.5) (5.9) (50e99) (40e95) (63e155) (27e56) (10e44)
CCA, common carotid artery; ICA, internal carotid artery. a In planned cases. b In necessary cases.
of the incision toward the sternal notch and division of the omohyoid muscle. Depending on patient anatomy, this maneuver allows for a safe placement of the proximal vascular clamp to the supraclavicular or even retroclavicular portion of the CCA, just a few centimeters distally to its origin from the aortic arch. Most frequently, these lesions are treated with open procedures. Technical options include open conventional endarterectomy through a longitudinal arteriotomy closed with a longitudinal suture or patch, interposition venous,17 or prosthetic bypass18,19 to the ICA with ECA reimplantation or extra-anatomic bypass. In a recent study, Sterpetti20 described a modified technique of eversion endarterectomy of the ICA combined with CCA endarterectomy to treat lesions of the distal CCA and ICA simultaneously. The DECE technique requires both an optimal radiologic assessment to properly evaluate the extension of the atherosclerotic plaque on the CCA and experience in performing standard eversion endarterectomy. DECE carries some discrete advantages. First, it avoids the use of exogenous material or a long longitudinal arteriotomy, which may require closure with a long patch. DECE can also be applied as a ‘‘bailout’’ procedure, in cases where there is a documented defect in the CCA during completion angiography after ECEA. This was the case in 4 patients in our series. In this subgroup, an intimal CCA defect rather than a true atherosclerotic lesion was documented intraoperatively, mandating immediate correction. Exploration of the CCA was performed after division of the CCA between clamps and distal eversion of its lumen, in order to directly visualize and correct the relevant defect. This resulted in a mean reclamping time of 16.2 min. Final angiography was satisfactory in all cases after re-exploration.
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The Vollmar ring has been criticized after significant complications related to its blind use to treat intramediastinal lesions of the CCA through a cervical incision. Although the Vollmar ring is being used in the treatment of atherosclerotic lesions in the periphery, its applicability in the CCA has only been described as a method to treat total occlusions in limited reports.21,22 The use of the Vollmar ring in the DECE technique is essential because it allows retrograde endarterectomy of the CCA from the ostium of the resected ICA down to the proximal clamp. Experience in the use of the Vollmar ring in other vascular beds23,24 and the technique of remote endarterectomy is advised, in order to avoid overstripping of the CCA, which could result in thinning of its wall and possible early or late pseudoaneurysm formation.25 In our series, we had no complications related to the use of the Vollmar ring. Endovascular or hybrid treatment of tandem lesions varies according to the location of the CCA lesion.2 Ostial lesions associated with ICA stenosis can benefit from hybrid treatment with CEA and retrograde CCA stenting, even though placement of the introducer sheath in the CCA can be risky in cases of diffuse CCA disease. Anterograde stenting of both CCA and ICA lesions is a plausible treatment modality, despite the increased embolic risk associated with it. Nevertheless, placement of a long stent in the CCA is questionable and not adequately supported in the literature. These stenting techniques are better suited for tandem carotid lesions involving the mediastinal CCA that are not accessible from a cervical incision.
CONCLUSION DECE represents an alternative technique to conventional open endarterectomy or bypass for the treatment of select tandem, nonostial carotid lesions. It is performed via a single cervical incision and can also be applied as a ‘‘bailout’’ technique for secondary defects of the CCA that occur during ECEA. However, experience in the use of the Vollmar ring and routine eversion endarterectomy is strongly advised. REFERENCES 1. Rouleau PA, Huston J 3rd, Gilbertson J, et al. Carotid artery tandem lesions: frequency of angiographic detection and consequences for endarterectomy. AJNR Am J Neuroradiol 1999;20:621e5. 2. Moore JD, Schneider PA. Management of simultaneous common and internal carotid artery occlusive disease in the endovascular era. SeminVasc Surg 2011;24:2e9.
Double eversion carotid endarterectomy 5
3. Linni K, Aspalter M, Ugurluoglu A, et al. Proximal common carotid artery lesions: endovascular and open repair. Eur J Vasc Endovasc Surg 2011;41:728e34. 4. Salam TA, Smith RB 3rd, Lumsden AB. Extrathoracic bypass procedures for proximal common carotid artery lesions. Am J Surg 1993;166:163e6. 5. Sfyroeras GS, Karathanos C, Antoniou GA, et al. A metaanalysis of combined endarterectomy and proximal balloon angioplasty for tandem disease of the arch vessels and carotid bifurcation. J Vasc Surg 2011;54:534e40. 6. Mays BW, Towne JB, Seabrook GR, et al. Intraoperative carotid evaluation. Arch Surg 2000;135:525e8. 7. Ricco JB, Regnault de la Mothe G, Fujita S, et al. Impact of routine completion angiography on the results of primary carotid endarterectomy: a prospective study in a teaching hospital. Eur J Vasc Endovasc Surg 2011;41:579e88. 8. Antonopoulos CN, Kakisis JD, Sergentanis TN, et al. Eversion versus conventional carotid endarterectomy: a metaanalysis of randomised and non-randomised studies. Eur J Vasc Endovasc Surg 2011;42:751e65. 9. Cao P, Giordano G, De Rango P, et al. Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg 2000;31(1 pt 1):19e30. 10. Coscas R, Rhissassi B, Gruet-Coquet N, et al. Open surgery remains a valid option for the treatment of recurrent carotid stenosis. J Vasc Surg 2010;51:1124e32. 11. Radak DJ, Tanaskovic S, Ilijevski NS, et al. Eversion carotid endarterectomy versus best medical treatment in symptomatic patients with near total internal carotid occlusion: a prospective nonrandomized trial. Ann Vasc Surg 2010;24: 185e9. 12. Ballotta E, Da Giau G. Selective shunting with eversion carotid endarterectomy. J Vasc Surg 2003;38:1045e50. 13. Black JH 3rd, Ricotta JJ, Jones CE. Long-term results of eversion carotid endarterectomy. Ann Vasc Surg 2010;24: 92e9. 14. Crawford RS, Chung TK, Hodgman T, et al. Restenosis after eversion vs patch closure carotid endarterectomy. J Vasc Surg 2007;46:41e8. 15. Darling RC 3rd, Mehta M, Roddy SP, et al. Eversion carotid endarterectomy: a technical alternative that may obviate patch closure in women. Cardiovasc Surg 2003;11:347e52. 16. Karathanos C, Sfyroeras GS, Stamoulis K, et al. Hybrid procedures for the treatment of multi-focal ipsilateral internal carotid and proximal common carotid or innominate artery lesions. Vasa 2011;40:241e5. 17. Branchereau A, Pietri P, Magnan PE, et al. Saphenous vein bypass: an alternative to internal carotid reconstruction. Eur J Vasc Endovasc Surg 1996;12:26e30. 18. Cormier JM, Cormier F, Laurian C, et al. Polytetrafluoroethylene bypass for revascularization of the atherosclerotic internal carotid artery: late results. Ann Vasc Surg 1987;1: 564e71. 19. Ricco JB, Marchand C, Neau JP, et al. Prosthetic carotid bypass grafts for atherosclerotic lesions: a prospective study of 198 consecutive cases. Eur J Vasc Endovasc Surg 2009;37:272e8. 20. Sterpetti AV. Eversion endarterectomy of the internal carotid artery combined with open endarterectomy of the common carotid artery. Am J Surg 2010;200:e44e7. 21. Aguiar ET, Lederman A, Matsunaga P. Ring-stripping retrograde common carotid endarterectomy: case report. Sao Paulo Med J 2002;120:154e7.
6 Georg et al.
22. Pinter L, Cagiannos C, Bakoyiannis CN, et al. Hybrid treatment of common carotid artery occlusion with ringstripper endarterectomy plus stenting. J Vasc Surg 2007; 46:135e9. 23. Nelson PR, Powell RJ, Proia RR, et al. Results of endovascular superficial femoral endarterectomy. J Vasc Surg 2001;34: 526e31.
Annals of Vascular Surgery
24. Van Den Dungen JJ, Boontje AH, Kropveld A. Unilateral iliofemoral occlusive disease: long-term results of the semiclosed endarterectomy with the ring-stripper. J Vasc Surg 1991;14:673e7. 25. Ilijevski NS, Gajin P, Neskovic V, et al. Postendarterectomy common carotid artery pseudoaneurysm. Vascular 2006; 14:177e80.
Background: We describe an original method to treat tandem lesions of the internal carotid artery (ICA) and the common carotid artery (CCA). In this manuscript, we describe a ‘‘double eversion carotid endarterectomy’’ technique (DECE) and report our results. Methods: A retrospective review in the medical records of patients that underwent DECE over a 15-year period was performed. Patient characteristics, operative details, preoperative imaging and lesion characteristics, perioperative outcomes, and follow-up data were documented and analyzed. Patients with ostial and mediastinal lesions were excluded from our study. Operations were divided into 2 categories: ‘‘planned,’’ when the lesions were identified during preoperative imaging, and ‘‘necessary’’ when performed for secondary defects of the CCA detected intraoperatively. Results: Between 1996 and 2011, a total of 15 patients with 17 tandem lesions underwent DECE. The mean age was 74.3 years. The mean degree of stenosis was 76.3% for the ICA and 61.5% for the CCA, with the majority of the lesions being asymptomatic (12/17). All procedures were performed under general anesthesia, and in 1 case an intraluminal shunt was used. The mean operative time was 83.4 min, with a mean primary clamping time of 29.2 min. In cases of secondary lesions, the mean reclamping time was 16.2 min. There was no mortality or major neurologic event within 30 days postoperatively. Postoperative complications included 2 major cardiac events and 1 case of cranial nerve XII injury that resolved during follow-up. There were no deaths or neurologic events during a mean follow-up of 27.5 months (range: 1e188 months). One patient required a reintervention after 5 years because of restenosis of the ICA. Conclusion: DECE is an alternative surgical technique for select tandem, nonostial carotid lesions. In addition, DECE can be performed as a ‘‘bailout’’ procedure for secondary CCA defects during conventional eversion carotid endarterectomy.
INTRODUCTION Significant combined tandem lesions of both the common carotid artery (CCA) and the internal carotid artery (ICA) are present in 10 min according to our surgical experience. When shunting is considered necessary, both anastomoses are performed around the shunt, leaving a few stiches before shunt removal in order to minimize cerebral ischemia.
RESULTS Seventeen tandem carotid lesions (6 on left and 11 on the right side) in 15 patients were treated using the DECE technique during the study period. The mean age at operation was 74.3 years (range: 42e84).
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Double eversion carotid endarterectomy 3
The primary risk factors included hypertension (70.6%), smoking (53%), hyperlipidemia (58.8%), coronary artery disease (53%), diabetes (5.9%) and chronic obstructive pulmonary disease (COPD) in 35.3% of cases. Six patients (35.3%) in this cohort were considered to have symptomatic disease, defined either as previous ipsilateral transient ischemic attack (TIA) or stroke. (Table I). Twelve (70.6%) and 2 (11.7%) patients underwent preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans, respectively. Duplex ultrasonography was the only preoperative imaging in 3 (17.6%) patients because of the impossibility to achieve a CT or MRI scan. The mean degree of ICA stenosis was 76.3% (range: 50e99%). We documented 13 cases of planned operations and 4 necessary procedures. In planned cases, the mean degree of CCA stenosis was 61.5% (range: 40e 95%). In necessary operations, CCA exploration with the DECE technique was performed for remaining defects in completion biplanar angiography. These were defined either as a CCA dissection or as a remaining CCA intimal tear. The mean operative time was 83.4 min (range: 63e155 min), with a mean clamping time of 29.2 min (range: 27e56 min). In cases of secondary lesions, the mean reclamping time was 16.2 min (range: 10e 44 min). In our institution, we follow a selective shunting policy. Criteria for shunting in our practice include recent TIA or stroke, contralateral ICA occlusion, and nonpulsatile ICA backflow intraoperatively. Shunt placement was considered necessary in 1 patient in this series (6.7%). Lesion characteristics and operative details are summarized in Table II. There were no strokes, TIAs, or deaths at 30 days. We documented 2 postoperative cardiac events. One was defined as a minor myocardial infarction, with elevated ST and troponin levels on
Fig. 1. Steps of the double eversion technique. (A) Eversion endarterectomy of the internal carotid artery (ICA) is performed first. (B) A circumferential dissection plane in the common carotid artery (CCA) is created with a spatula. (C and D) After placement of a second safety clamp in the CCA, the dissection plane is advanced proximally using a spatula or a Vollmar ring stripper (Aesculap, San Jose, CA). (E) The safety clamp is removed and the CCA is sharply sectioned using Potts scissors at this very level. (F) The endarterectomized cylinder is grasped with a mosquito clamp through the bulbar incision and the CCA is everted using gentle traction. (G) After removal of the plaque, the CCA is inverted and reset in the correct anatomic position. (H) After reimplantation of the ICA in the bulb and distal declamping, the CCA is anastomosed between clamps.
4 Georg et al.
Annals of Vascular Surgery
Table I. Comorbidities and main risk factors Comorbidity or risk factor
n (%)
Symptomatic (ipsilateral TIA or stroke) Hypertension Diabetes Smoking Hyperlipidemia CAD COPD
6 12 1 9 10 9 6
(35.3) (70.6) (5.9) (53) (58.8) (53) (35.3)
CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; TIA, transient ischemic attack.
postoperative day 2. The second was a nonfatal cardiac arrest during reintubation of a patient with an evolving postoperative hematoma that caused acute respiratory distress and required emergent reexploration. The same patient had aspiration pneumonia after reintubation that required prolonged ventilation. There was 1 case of cranial nerve XII palsy, which resolved completely on follow-up. All patients were followed up postoperatively with duplex ultrasonographic studies at regular intervals. In cases of suspected restenosis, CT angiography or conventional angiography was performed. The mean follow-up period was 27.5 months (range: 1e166 months). There were no deaths or major neurologic events during followup. We documented 1 asymptomatic restenosis of the ICA (>50% reduction of the vessel lumen diameter) after 5 years. This case required reintervention using patch repair; however, the same patient developed critical ipsilateral stenosis of the common trunk and the ostium of the CCA 6 years later. This was treated with carotidecarotid bypass with a polytetrafluoroethylene graft. The patient remains well 11 years after the first operation.
DISCUSSION The natural history of tandem carotid lesions and the contribution of CCA lesions to cerebrovascular ischemic events are not well defined. Treatment options for tandem ostial CCA and ICA lesions have been described and recently debated in the literature, with open, endovascular, and hybrid techniques showing satisfactory short- and long-term results.2,3,16 However, tandem nonostial lesions of the CCA and ICA have received less attention. Management mostly depends upon the location and length of the lesion of the CCA and essentially upon surgical accessibility to the proximal, nondiseased segment of the CCA. In most cases, access to the proximal CCA can be facilitated by extension
Table II. Lesion characteristics and operative details Perioperative parameter
n (% or range)
Planned operations, n (%) Necessary operations, n (%) Shunt placement, n (%) Mean % ICA stenosis (range) Mean % CCA stenosisa (range) Operative time, min (range) Clamping time, min (range) Re-clamping time, minb (range)
13 4 1 76.30 61.50 83.4 29.2 16.2
(76.5) (23.5) (5.9) (50e99) (40e95) (63e155) (27e56) (10e44)
CCA, common carotid artery; ICA, internal carotid artery. a In planned cases. b In necessary cases.
of the incision toward the sternal notch and division of the omohyoid muscle. Depending on patient anatomy, this maneuver allows for a safe placement of the proximal vascular clamp to the supraclavicular or even retroclavicular portion of the CCA, just a few centimeters distally to its origin from the aortic arch. Most frequently, these lesions are treated with open procedures. Technical options include open conventional endarterectomy through a longitudinal arteriotomy closed with a longitudinal suture or patch, interposition venous,17 or prosthetic bypass18,19 to the ICA with ECA reimplantation or extra-anatomic bypass. In a recent study, Sterpetti20 described a modified technique of eversion endarterectomy of the ICA combined with CCA endarterectomy to treat lesions of the distal CCA and ICA simultaneously. The DECE technique requires both an optimal radiologic assessment to properly evaluate the extension of the atherosclerotic plaque on the CCA and experience in performing standard eversion endarterectomy. DECE carries some discrete advantages. First, it avoids the use of exogenous material or a long longitudinal arteriotomy, which may require closure with a long patch. DECE can also be applied as a ‘‘bailout’’ procedure, in cases where there is a documented defect in the CCA during completion angiography after ECEA. This was the case in 4 patients in our series. In this subgroup, an intimal CCA defect rather than a true atherosclerotic lesion was documented intraoperatively, mandating immediate correction. Exploration of the CCA was performed after division of the CCA between clamps and distal eversion of its lumen, in order to directly visualize and correct the relevant defect. This resulted in a mean reclamping time of 16.2 min. Final angiography was satisfactory in all cases after re-exploration.
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The Vollmar ring has been criticized after significant complications related to its blind use to treat intramediastinal lesions of the CCA through a cervical incision. Although the Vollmar ring is being used in the treatment of atherosclerotic lesions in the periphery, its applicability in the CCA has only been described as a method to treat total occlusions in limited reports.21,22 The use of the Vollmar ring in the DECE technique is essential because it allows retrograde endarterectomy of the CCA from the ostium of the resected ICA down to the proximal clamp. Experience in the use of the Vollmar ring in other vascular beds23,24 and the technique of remote endarterectomy is advised, in order to avoid overstripping of the CCA, which could result in thinning of its wall and possible early or late pseudoaneurysm formation.25 In our series, we had no complications related to the use of the Vollmar ring. Endovascular or hybrid treatment of tandem lesions varies according to the location of the CCA lesion.2 Ostial lesions associated with ICA stenosis can benefit from hybrid treatment with CEA and retrograde CCA stenting, even though placement of the introducer sheath in the CCA can be risky in cases of diffuse CCA disease. Anterograde stenting of both CCA and ICA lesions is a plausible treatment modality, despite the increased embolic risk associated with it. Nevertheless, placement of a long stent in the CCA is questionable and not adequately supported in the literature. These stenting techniques are better suited for tandem carotid lesions involving the mediastinal CCA that are not accessible from a cervical incision.
CONCLUSION DECE represents an alternative technique to conventional open endarterectomy or bypass for the treatment of select tandem, nonostial carotid lesions. It is performed via a single cervical incision and can also be applied as a ‘‘bailout’’ technique for secondary defects of the CCA that occur during ECEA. However, experience in the use of the Vollmar ring and routine eversion endarterectomy is strongly advised. REFERENCES 1. Rouleau PA, Huston J 3rd, Gilbertson J, et al. Carotid artery tandem lesions: frequency of angiographic detection and consequences for endarterectomy. AJNR Am J Neuroradiol 1999;20:621e5. 2. Moore JD, Schneider PA. Management of simultaneous common and internal carotid artery occlusive disease in the endovascular era. SeminVasc Surg 2011;24:2e9.
Double eversion carotid endarterectomy 5
3. Linni K, Aspalter M, Ugurluoglu A, et al. Proximal common carotid artery lesions: endovascular and open repair. Eur J Vasc Endovasc Surg 2011;41:728e34. 4. Salam TA, Smith RB 3rd, Lumsden AB. Extrathoracic bypass procedures for proximal common carotid artery lesions. Am J Surg 1993;166:163e6. 5. Sfyroeras GS, Karathanos C, Antoniou GA, et al. A metaanalysis of combined endarterectomy and proximal balloon angioplasty for tandem disease of the arch vessels and carotid bifurcation. J Vasc Surg 2011;54:534e40. 6. Mays BW, Towne JB, Seabrook GR, et al. Intraoperative carotid evaluation. Arch Surg 2000;135:525e8. 7. Ricco JB, Regnault de la Mothe G, Fujita S, et al. Impact of routine completion angiography on the results of primary carotid endarterectomy: a prospective study in a teaching hospital. Eur J Vasc Endovasc Surg 2011;41:579e88. 8. Antonopoulos CN, Kakisis JD, Sergentanis TN, et al. Eversion versus conventional carotid endarterectomy: a metaanalysis of randomised and non-randomised studies. Eur J Vasc Endovasc Surg 2011;42:751e65. 9. Cao P, Giordano G, De Rango P, et al. Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg 2000;31(1 pt 1):19e30. 10. Coscas R, Rhissassi B, Gruet-Coquet N, et al. Open surgery remains a valid option for the treatment of recurrent carotid stenosis. J Vasc Surg 2010;51:1124e32. 11. Radak DJ, Tanaskovic S, Ilijevski NS, et al. Eversion carotid endarterectomy versus best medical treatment in symptomatic patients with near total internal carotid occlusion: a prospective nonrandomized trial. Ann Vasc Surg 2010;24: 185e9. 12. Ballotta E, Da Giau G. Selective shunting with eversion carotid endarterectomy. J Vasc Surg 2003;38:1045e50. 13. Black JH 3rd, Ricotta JJ, Jones CE. Long-term results of eversion carotid endarterectomy. Ann Vasc Surg 2010;24: 92e9. 14. Crawford RS, Chung TK, Hodgman T, et al. Restenosis after eversion vs patch closure carotid endarterectomy. J Vasc Surg 2007;46:41e8. 15. Darling RC 3rd, Mehta M, Roddy SP, et al. Eversion carotid endarterectomy: a technical alternative that may obviate patch closure in women. Cardiovasc Surg 2003;11:347e52. 16. Karathanos C, Sfyroeras GS, Stamoulis K, et al. Hybrid procedures for the treatment of multi-focal ipsilateral internal carotid and proximal common carotid or innominate artery lesions. Vasa 2011;40:241e5. 17. Branchereau A, Pietri P, Magnan PE, et al. Saphenous vein bypass: an alternative to internal carotid reconstruction. Eur J Vasc Endovasc Surg 1996;12:26e30. 18. Cormier JM, Cormier F, Laurian C, et al. Polytetrafluoroethylene bypass for revascularization of the atherosclerotic internal carotid artery: late results. Ann Vasc Surg 1987;1: 564e71. 19. Ricco JB, Marchand C, Neau JP, et al. Prosthetic carotid bypass grafts for atherosclerotic lesions: a prospective study of 198 consecutive cases. Eur J Vasc Endovasc Surg 2009;37:272e8. 20. Sterpetti AV. Eversion endarterectomy of the internal carotid artery combined with open endarterectomy of the common carotid artery. Am J Surg 2010;200:e44e7. 21. Aguiar ET, Lederman A, Matsunaga P. Ring-stripping retrograde common carotid endarterectomy: case report. Sao Paulo Med J 2002;120:154e7.
6 Georg et al.
22. Pinter L, Cagiannos C, Bakoyiannis CN, et al. Hybrid treatment of common carotid artery occlusion with ringstripper endarterectomy plus stenting. J Vasc Surg 2007; 46:135e9. 23. Nelson PR, Powell RJ, Proia RR, et al. Results of endovascular superficial femoral endarterectomy. J Vasc Surg 2001;34: 526e31.
Annals of Vascular Surgery
24. Van Den Dungen JJ, Boontje AH, Kropveld A. Unilateral iliofemoral occlusive disease: long-term results of the semiclosed endarterectomy with the ring-stripper. J Vasc Surg 1991;14:673e7. 25. Ilijevski NS, Gajin P, Neskovic V, et al. Postendarterectomy common carotid artery pseudoaneurysm. Vascular 2006; 14:177e80.
