Carotid Artery Remodeling following Modified Eversion Carotid Endarterectomy

Objective Modified eversion carotid endarterectomy (meCEA) is an alternative to classical patch angioplasty or eversion carotid endarterectomy, in which plaque is everted through a longitudinal arteriotomy over the common carotid artery (CCA) without transection of the internal carotid artery (ICA). Because primary repair of a longitudinal arteriotomy may raise concern for postoperative narrowing, we evaluated postoperative carotid geometry after meCEA in patients with paired preoperative and postoperative computed tomography angiography (CTA). Methods We performed a single-center retrospective review of all meCEA procedures performed between 2009 and 2022. Patients were included in the imaging analysis if both preoperative and postoperative CTA were available. Pre- and postoperative centerline measurements, by two independent observers, were obtained at 1 cm and 2 cm proximal to the ICA ostium within the CCA (CCA1 and CCA2, respectively), the ICA ostium (ICA0), and 1 cm and 2 cm distally within the ICA (ICA1 and ICA2, respectively). Preoperative and postoperative diameters at each arterial segment were compared using paired t-tests. Results Among 480 meCEA procedures performed during the study period, 40 carotid arteries had paired pre-operative and post-operative CTAs available for analysis. Median time to postoperative imaging was 433 days (range, 0 – 1186 days). Mean preoperative diameters were 7.6 mm at CCA2, 8.2 mm at CCA1, 6.8 mm at ICA0, 6.0 mm at ICA1, and 5.2 mm at ICA2. Postoperatively, weighted diameter change was –5.4% at CCA2 (p = 0.36), –10.9% at CCA1 (p = 0.063), -2.1% at ICA0 (p = 0.87), +10.7% at ICA1 (p = 0.23), and +6.1% at ICA2 (p = 0.47). None of these changes reached statistical significance. Conclusions In this selected imaging cohort, meCEA with primary closure was not associated with statistically significant adverse narrowing of the ICA on follow-up imaging. Distal ICA measurements trended upwards, whereas CCA measurements trended downward, but these findings were exploratory and may not be generalizable to the full meCEA population. These data support the interpretation that meCEA does not appear to cause marked adverse ICA narrowing in this selected series; however, standardized imaging surveillance and comparative studies are needed to define long-term geometric and clinical outcomes more clearly.