Patch angioplasty in carotid endarterectomy. Advantages, concerns, and controversies.

There is much controversy in the literature regarding the precise role of patch angioplasty in carotid endarterectomy. Our report summarizes the theoretical and experimental considerations, including the hemodynamic effects and biologic behavior of the graft, associated with this technique. We present a detailed review of the literature regarding the clinical efficacy of patch angioplasty in carotid endarterectomy, including the early results, the late results, and the incidence and nature of carotid restenosis. We address concerns about the use of patch angioplasty, including the duration of cross-clamping, potential problems with the graft and suture-line disruption, and graft atherogenesis. We conclude that most recent literature indicates that patch angioplasty decreases acute complications (notably carotid occlusion) after carotid endarterectomy and prevents or delays carotid restenosis. As pressure increases to achieve a minimal rate of perioperative morbidity, many surgeons are expected to adopt patch angioplasty in more of their cases. However, in the absence of conclusive results from a prospective randomized study, opinion will continue to be divided regarding the routine versus the selective use of patch grafting in carotid endarterectomy. We present criteria for randomized trials of this technique.