1. 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

2. 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

3. 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%

4. 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%

5. 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

6. 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

7. 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

8. Dissection and identification
Technique
Dissection and identification
ICA
ECA
CCA

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

10. Technique
ICA anasotmosis
CCA anastomosis

11. 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

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

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

14. 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%

15. 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)

16. 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)

17. 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

18. Restenosis free survival

19. 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

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

22. 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

23. 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

24. 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.
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.
Becquemin, J. P., Cavillon, A., Brunel, M., Desgranges, P., & Melliere, D. (1996). Polytetrafluoroethylene grafts for carotid repair. Cardiovascular Surgery.
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.
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.
Veldenz, H. C., Kinser, R., & Yates, G. N. (2005). Carotid graft replacement: A durable option. Journal of Vascular Surgery.
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.