Modified Eversion Carotid Endarterectomy is Potentially Associated with Improved Surgical Outcomes-Systematic Review and Meta-Analysis of the Clinical Efficacy of Modified Eversion Carotid Endarterectomy.

BACKGROUND: Stroke is a leading cause of mortality worldwide, with carotid stenosis contributing to approximately 20-25% of cases. Carotid endarterectomy (CEA) has been the standard surgical treatment for carotid stenosis since its implementation in 1953. Among the various CEA techniques, modified eversion CEA (meCEA) has been proposed as a promising alternative because of its potential to reduce operative time and avoid patch closure. However, the clinical efficacy of meCEA has not yet been thoroughly evaluated. This study aimed to address this knowledge gap and evaluate the clinical efficacy of this novel technique.

METHODS: A systematic review and meta-analysis were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, supplemented by Meta-analysis of Observational Studies in Epidemiology recommendations. PubMed, EMBASE, and the Cochrane Library databases were searched to identify studies that compared meCEA with other surgical techniques, including conventional CEA (cCEA) and eCEA. Randomized controlled trials and retrospective comparative cohort studies were included. Data were extracted and analyzed for postoperative outcomes (mortality, stroke, and cranial nerve injury) and intraoperative variables (shunt and patch use, operative time, and internal carotid artery clamp time). Risk of bias was assessed using risk of bias in randomized trials and Risk of Bias in Nonrandomized Studies of Interventions-I tools.

RESULTS: Of the 1,069 studies identified, 6 retrospective cohort studies were included in the meta-analysis. The use of intraoperative shunts and patches was significantly lower in the meCEA group than that in the cCEA groups. Although 2 studies reported significantly shorter operative and internal carotid artery clamp times in the meCEA group, the meta-analysis did not confirm the statistical significance of these parameters. The incidence of postoperative stroke was significantly lower in the meCEA group (P = 0.01), whereas no differences were observed in the incidence of postoperative mortality, transient ischemic attack, or cranial nerve injury. Follow-up data revealed no significant differences in long-term stroke rates or restenosis between meCEA and cCEA.

CONCLUSION: Compared to cCEA techniques, meCEA was associated with reduced incidence of postoperative stroke and minimized shunt and patch usage. Hence, meCEA has significant potential for improved surgical outcomes. However, evidence from current studies is limited by bias and heterogeneity, emphasizing the need for high-quality, multicenter, randomized controlled trials. Future research should focus on standardizing the patient selection criteria and exploring the lesion-specific benefits of meCEA to establish its role in clinical practice.