Belgian Surgical Week Vascular session Ghent, 7/5/2015 Carotid Bifurcation Resection and Interposition of a PTFE Graft (BRIG) for carotid disease. A retrospective study of 120 consecutive BRIG procedures. Ian DIEBELS, Emilio CANOVAI, Yannick MANDEVILLE, Marc DUBOIS, Philippe DE VLEESCHAUWER Department of Vascular Surgery, Heilig Hart Ziekenhuis, Lier, Belgium Which we called the BRIG procedure BSVS

Introduction Carotid endarterectomy: gold standard However: restenosis is an important unresolved issue: 7.3% after 1 year (Bond 2004, n= 901) 12.2% restenosis after 2 years (LaMuraglia 2005, n=2127) 6.3% restenosis after 2 years (CREST 2012, n= 1105) Alternative techniques Eversion endarterectomy Bypass grafting Interposition grafting Stenting

Bypass grafting Courmier et al. Courmier et al. Study, year Cases, Materials Restenosis rate Events 30d Mortality Cormier, 1987 62 PTFE 3,2% 5% 0% Becquemin, 1998 32 PTFE 109, GSV 11% 3% Camiade, 2003 110, PTFE 16,4% 1,8% Ricco, 2008 198 PTFE 3,5% 0,5%

Interposition grafting Dorafshar et al. Sise et al. Study, year Cases, material Restenosis rate Events 30d Mortality Sise, 1992 23, PTFE 16% 0% 4% Lauder, 2002 40, GSV 11% 5% Veldenz, 2005 51, PTFE 2,2% 1,9% Dorafshar, 2008 31, PTFE 10, GSV 10% 4,9%

Question 1 What is your primary treatment of choice for significant carotid artery stenosis? Endarterectomy with patch plasty Eversion endartectomy Carotid artery bypass grafting Carotid resection with graft replacement Carotid artery stenting

Question 2 In case of significant restenosis, what is your treatment of choice? Endarterectomy with patch plasty Eversion endartectomy Carotid artery bypass grafting Carotid resection with graft replacement Carotid artery stenting

Methodology Retrospective study march 2007 – feb. 2015 120 consecutive BRIG-procedures Single centre - single surgeon Dr. P. De Vleeschauwer Initial indications Restenosis after CEA Pseudo-aneurysm Peroperative extensive sclerotic disease Difficult anatomy Standard treatment of choice: ≥2010

Dissection and identification Technique Dissection and identification ICA ECA CCA

Bifurcation resection and ECA ligation Technique Bifurcation resection and ECA ligation Ligated ECA CCA ICA

Technique ICA anasotmosis CCA anastomosis

Technique Running end-to-end suture Proximal: straight artery and straight or angulated graft Distal: Artery and graft both angulated CCA: 6mm 6mm PTFE graft CCA > 6mm 6mm PTFE graft ICA 6mm PTFE graft

Bifurcation grafts (n=14) Indication: bilateral BRIG or contralateral occlusion Reimplantion of ECA

Follow-up 1 month post-op, then yearly follow-up Ultrasound CT-angio MR-angio, if CT contra-indicated

Results (n=120) Demographics Mean age 70,8 y Gender: 83,3% male Cardiac Risk Factors Diabetes 26,7% Smoking 61,9% Hypertension 70% Hypercholesterolemia 60,8% Previous CV-disease 58,3% Family History of CV-disease 33%

Results Indication Symptomatic: 52,5% Operative results Revision previous CEA: 5,8% Pseudo-aneurysm: 2,5% Stenosis grade 80 – 99%: 87,5% Symptomatic: 52,5% Operative results Mean clamping time: 32,7 min Mean operating time: 110 min Mean graft lengte: 4,8 cm (1,5 – 11cm)

Results Post-op events: Local complications: Revision: 4 (3,2%) Minor stroke: 2 (1,6%) Both with only residual fine motor impairment Major stroke: 1 (0,8%) Local complications: Jaw claudication: 1 (0,8%) Hemorrhage: 2 (1,6%) Infection: 1 (0,8%), superficial SSI Revision: 4 (3,2%) 2 patients with hemorrhage (1,6%) 2 patients with strokes (1,6) In both graft kinking led to thrombosis, due to to extensive graft length (10 and 11 cm)

Results Mean follow-up: 25 months (1 – 90 months) Mortality: Short term (<30d): 0,8% 1 Surgery related Long term: 12% 0 surgery related 5 CV-related deaths (4,0%) 6 non-CV related deaths (4,8%) Restenosis: 2 (1,6%) 2 patients: 50% restenosis at proximal anastomis

Restenosis free survival

MRI angio: Jan 2015 ( 7,5 years postop) Case illustration PTFE Carotid graft for asymptomatic stenosis of the left ICA (male, 62.) MRI angio: Jan 2015 ( 7,5 years postop) MRI angio: Aug 2007

Duplex ultrasound: 7,5 years postop Proximal anastomosis Distal anastomosis

Conclusion Promising alternative to CEA Simplified surgical technique No meticulous endarterectomy No distal intima fixation No trombogenic surface No difficult carotid shortening in case of coiling and kinking Short clamping times

Question 3 Would you consider using the BRIG procedure? yes, even as primary treatment for carotid disease Yes, but only in extremely hostile carotids Yes, after CEA attempts fail Maybe, but I demand more scientific evidence Never

References Cormier, J. M., Cormier, F., Laurian, C., Gigou, F., Fichelle, J. M., & Bokobza, B. (1987). Polytetrafluoroethylene bypass for revascularization of the atherosclerotic internal carotid artery: late results. Annals of Vascular Surgery. http://doi.org/10.1016/S0890-5096(06)61441-6 Camiade, C., Maher, A., Ricco, J. B., Roumy, J., Febrer, G., Marchand, C., … Archie, J. P. (2003). Carotid bypass with polytetrafluoroethylene grafts: A study of 110 consecutive patients. Journal of Vascular Surgery. http://doi.org/10.1016/S0741-5214(03)00708-0 Becquemin, J. P., Cavillon, A., Brunel, M., Desgranges, P., & Melliere, D. (1996). Polytetrafluoroethylene grafts for carotid repair. Cardiovascular Surgery. http://doi.org/10.1016/S0967-2109(96)00023-3 LaMuraglia, G. M., Stoner, M. C., Brewster, D. C., Watkins, M. T., Juhola, K. L., Kwolek, C., … Cambria, R. P. (2005). Determinants of carotid endarterectomy anatomic durability: Effects of serum lipids and lipid-lowering drugs. Journal of Vascular Surgery. http://doi.org/10.1016/j.jvs.2005.01.035 Ricco, J. B., Marchand, C., Neau, J. P., Marchand, E., Cau, J., & Fébrer, G. (2009). Prosthetic Carotid Bypass Grafts for Atherosclerotic Lesions: A Prospective Study of 198 Consecutive Cases. European Journal of Vascular and Endovascular Surgery. http://doi.org/10.1016/j.ejvs.2008.11.012 Veldenz, H. C., Kinser, R., & Yates, G. N. (2005). Carotid graft replacement: A durable option. Journal of Vascular Surgery. http://doi.org/10.1016/j.jvs.2005.04.004 Sise, M. J., Ivy, M. E., Malanche, R., & Ranbarger, K. R. (1992). Polytetrafluoroethylene interposition grafts for carotid reconstruction. Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. http://doi.org/10.1016/0741-5214(93)90134-8