Does the eversion technique have a lower early postoperative stroke rate than the conventional technique in carotid endarterectomy?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In carotid surgery, Does the eversion technique (ECEA) has an early postoperative lower stroke rate, As compared to conventional carotid endarterectomy (CCEA)? The outcome assessed was the stroke rate in the early potoperative period (30 days) in the two techniques. The best evidence confirmed that there is no statistically significant difference between ECEA and CCEA regarding the early postoperative stroke incidence.


Introduction
This BET was designed using a framework outlined by the International Journal of Surgery [1]. This format was used because a preliminary literature search suggested that the available evidence is insufficient to perform a meaningful meta-analysis. A BET provides evidence-based answers to common clinical questions using a systematic literature review. The outcome assessed was the stroke rate in the early potoperative period (30 days) in the two techniques. The best evidence confirmed that there is no statistically significant difference between ECEA and CCEA regarding the early postoperative stroke incidence.

Clinical scenario
While reviewing a 67-year-old man on day-1 post carotid endarterectomy using eversion technique, one of the junior doctors asked; Does the eversion technique has lower early postoperative stroke rates than the conventional endarterectomy? The results were limited to English articles and human studies.

Three parts question
• Inclusion criteria: all original articles review the postoperative stroke incidence among patients who underwent carotid endarterectomy using conventional or eversion techniques.
• Exclusion criteria: case reports, letters to the editor, conference abstracts and systematic reviews, and meta-analysis.

Search outcome
Using both search engines, we found a total of 172 articles. We excluded one hundred twenty-six articles because they were irrelevant based on the titles and or the abstracts. Forty-six full-text articles were screened and assessed for eligibility. We identified six papers to provide the best evidence to answer the question (see Table 1).

Result
see Table 1 7

. Discussion
Eversion and Conventional endarterectomy with primary closure or patch angioplasty are the most common surgical techniques of endarterectomy in the management of carotid artery disease [8].
The Conventional endarterectomy with primary closure is associated with higher restenosis rates, while using the patch is associated with higher infection rates. European guidelines of the European Society of Vascular Surgery and the Dutch society for vascular surgery consider CEA with patch angioplasty as the reference technique [9].
The main advantage of the ECEA is that there is no need for a patch that minimizes the operative time and risk of postoperative infection. However, the difficulty of inserting the shunt before removing the plaque and the high rates of postoperative hypertension due to transecting the carotid sinus nerve branches and loss of baroreceptors limit its use [9,10].
In this article, we reviewed the best studies which compared the ECEA to the CCEA, considering the early postoperative significant stroke rates.
Five of the six studies in our review are observational studies [3][4][5][6][7] and only one is a randomized trial [2]. Two studies had a large sample size of more than 1000 patients [2,3]. There was no significant difference in early postoperative stroke incidence, the exception being Demirel et al. study that reported a statistically significant high early postoperative stroke incidence in ECEA (9% versus 3%; p = 0.005). However, it appeared to offer higher protection from stroke between 30 days and two years post-operatively, as the 2-year risk of ipsilateral stroke in this study was significantly higher in the conventional CEA group (2.9% versus 0%; p = 0.017) [5].
This may because of the small sample size, and the fact that the choice of the endarterectomy echnique was left to the surgeons. Some surgeons or centers wouls prefer one technique over another. High or low surgeon related or centre-specific complications coiuldnot be ruled out in the analysis [5]. Our review was limited by the relatively weak level of evidence as there is only one randmised study and all the conventional endarterectomy comparisons included the primary closure and the patch angioplasty.

Ethical approval
Ethical approval was not required.

Source of funding
No source of funding

Clinical bottom line
According to the above articles, the best evidence shows no significant difference between ECEA and CCEA regarding the early postoperative stroke incidence.

Trail registry number
None.

Declaration of competing interest
No conflicts of interest.