Vein Patch Rupture After Carotid Endarterectomy: A Survey of the Western Vascular Society Members Roy L. Tawes, Jr., MD, Richard L. Treiman, MD, San Mateo, Califi)rnia
To determine the prevalence, demographics and morbidity of vein patch rupture, the authors polled members of the Western Vascular Society. Forty-eight surgeons (53% of the members) reported an experience with 23,873 carotid operations. A vein patch was used in 1,760 operations (7.4%), and rupture of the patch occurred in 13 patients (0.7%), 10 women and three men. Indications for the patch were a small artery in 10 patients and restenosis in three. Saphenous vein was used for all patches and was harvested from the ankle in 12 patients and from the groin in one patient. All ruptures occurred from a split in the vein patch. Hypertension was present in seven of the 13 patients. None of the ruptures were associated with infection. Two ruptures occurred on the first postoperative day, six on the second day, three on the third day, one on the eighth day, and one on the twenty-first day. Four patients died: airway obstruction (1), hemorrhagic cerebral infarction (1), and myocardial infarction (2) were the causes. Three had a stroke and survived, one had a retinal embolus, and five underwent reoperation without complication. Vein patch of the carotid artery is used infrequently by members of the Western Vascular Society. The incidence of rupture of the patch is low (0.7%), but when it occurs, there is significant mortality (30.7%), and morbidity (30.7%). Patients with a vein patch should be observed in the hospital for three days after endarterectomy because rupture demands immediate reoperation. (Ann Vasc Surg 1991;5:71-73).
KEY WORDS: Vein patch angioplasty; rupture, vein patch; carotid endarterectomy; Western Vascular Society; vascular surgery.
Vein patch angioplasty is an accepted technique for closure of the carotid artery after endarterectomy. Rupture of the patch or blowout occurs infrequently. Consequently, most surgeons have little experience with this life-threatening complication. To determine the prevalence, demographics, morbidity, and mortality of vein patch rupture (VPR), the authors surveyed members of the Western Vascular Society. This report is a summary of the results of this survey.
PATIENTS AND METHODS Questionnaires were sent to the 90 vascular surgeons in the Western Vascular Society. Forty-eight surgeons (53%) responded, reporting a collective experience with 23,873 carotid arteries after endarterectomy. One thousand seven hundred sixty patients (7.4%) had saphenous vein patch angioplasty. The surgeons' experience ranged from five to 32 years (mean 16 years). Rupture of the vein patch occurred in 13 patients (0.7%).
Presented at the Western Vascular Society Meeting, Coronado, California, January 25-28, 1990. Reprint requests: Roy L. Tawes, Jr., MD, 101 S. San Mateo Drive #112, San Mateo, California 94401.
Demographics
Ten patients with a ruptured patch were female (77%) and three were male. Their ages ranged from 71
VEIN PATCH RUPTURE
72
65 to 80 years (mean 73 years). The indication for a vein patch angioplasty was a small internal carotid artery in 10 (-+ 3 mm) and operation for restenosis in three. Saphenous vein was the source of the patch in all 13 patients and was harvested from the ankle in 12 and from the groin in one. In all cases, the vein patch rupture resulted from a split in the saphenous vein. In no case did a suture break or a tie on a tributary unravel. None of the wounds were infected. Postoperative hypertension was present in seven of the 13 patients. In two patients, vein patch rupture occurred on the first postoperative day, in six on the second day, and in three on the third day: There were two late ruptures at eight and 21 days after operation. Mortality and morbidity
Vein patch rupture was associated with a serious complication or death in eight patients (61%). Three patients suffered a major stroke, one developed a retinal hemorrhage (a complication rate of 30.7%). Four patients died, representing a mortality of 30.7%. One died from airway obstruction, two from myocardial infarction and one from hemorrhagic cerebral infarction.
DISCUSSION Patch graft angioplasty has been recommended to obtain better early patency, decrease the risk of postoperative thrombosis, and prevent late restenosis. From conversations with colleagues, it appears that the enthusiasm for patch graft angioplasty following carotid endarterectomy varies regionally and is usually reserved for closure of small internal carotid arteries (ICA) and repair of recurrent stenoses. A review of the literature reveals sparse information, however, regarding the complication of vein patch rupture. Hertzer and associates reported three vein patch ruptures in 433 patients with one stroke [1]. Subsequent communication from the Cleveland Clinic reported an incidence of 0.7% for this complication (N. Hertzer, personal communication, 1990). Hans and colleagues reported no patch graft ruptures in 83 patients [2]. Archie and coworkers reported vein patch rupture in two of 416 for saphenous vein patch reconstructions, an incidence of 0.5% [3]. Archie studied the hemodynamics of vein patch rupture and concluded that saphenous vein diameter is the primary determinant of rupture due to stress. Eikelboom and associates reported one vein patch rupture on the second postoperative day in 67 patients having vein patch angioplasty [4]. The paucity of reports on vein patch rupture suggests that this complication is an unusual occurrence and probably underreported.
ANNALS OF VASCULAR SURGERY
Riles and colleagues will report next year in Surgery on rupture of saphenous vein patch taken from the ankle in three of 75 patients (4%). They have had no ruptures of vein patches harvested from the groin in over 2,000 carotid angioplasties [5]. If vein patch angioplasty gains in popularity, vascular surgeons must be acquainted with this potential complication to avoid high mortality and severe morbidity associated with this catastrophic event. Vein patch rupture or blowout is a dramatic event, presenting with an expanding hematoma in the operativ e site and associated with airway distress, neurologic deficit or hemodynamic deterioration. Emergency treatment requires prompt intubation. If intubation cannot be performed with a large hematoma present, it may be necessary to open the wound and apply direct pressure over the vein patch rupture. All 13 blowouts resulted from a split in the saphenous vein. Suture repair is not advised and, in our opinion, the artery should be repaired with a synthetic patch. Surgeons in their attempt to decrease the restenosis rate by using vein patch angioplasty may be subjecting patients to a potential complication in a small number of cases. Restenosis is usually asymptomatic and is associated with a low stroke rate [6]. With current techniques using magnifying loups, many small internal carotid arteries can be closed safely without a patch. It could be argued that vein patch angioplasty should be used selectively not routinely. This study does not address the issue of whether patches should be used at all and, if used, what is the best patch material. Carney and Lilly evaluated patch material, but did not address the problem of vein patch rupture [7]. The purpose of this report is to focus attention on an infrequent, but severe complication of vein patch angioplasty. It is generally accepted that small arteries and operations for restenosis require a patch. A prospective randomized study is needed to determine the best patch material to prevent blowout. An additional consideration involves reimbursement based on diagnosis-related groups (DRGs). In the present climate of concern regarding hospital costs and length of stay, our data justify not discharging the patient undergoing carotid endarterectomy with a vein patch until the third or fourth postoperative day. In this study, six of the 13 vein patch ruptures occurred on the second postoperative day; in three cases after intravenous nitroprusside had been weaned and the patient experienced significant recurrent hypertension. Approximately 80,000 carotid endarterectomies were performed in 1988. If 7.4% of the surgeons used a vein patch, this represents an additional approximate cost of $5.92 million to observe 5,920 patients an extra day, assuming a cost basis of $1,000/day, which may be a low estimate. If the incidence of vein patch
VOLUME 5 NO 1 - 1991
VEIN PATCH RUPTURE
rupture is 0.7%, 414 patients annually might rupture their vein patch, suffering a 61% serious complication rate. Perhaps one extra day of observation would decrease this projected mortality and morbidity.
CONCLUSIONS
In summary, members of the Western Vascular Society use vein patch angioplasty infrequently (7.4%). The incidence of vein patch rupture is low (0.7%) but is associated with a significant mortality (30.7%) and morbidity (30.7%). Patients with a carotid vein patch require careful control of hypertension and observation in the hospital for at least three days after carotid endarterectomy. Most vein patch ruptures occur one to three days after operation and require immediate reoperation. The purpose of this paper is to alert vascular surgeons to this unusual, but hazardous complication.
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73
REFERENCES
1. H E R T Z E R NR, B E V E N EG, O ' H A R A PJ, et al. A pro-
spective study of vein patch angioplasty during carotid endarterectomy. Ann Surg 1987;206:628-635. 2. H A N S SS, G I R I S H K U M A R H, H A N S B. Vein patch grafts and carotid endarterectomy. Arch Surg 1987;122:1134-1138. 3. A R C H I E JP Jr, G R E E N JJ. Saphenous vein rupture pressure, rupture stress and carotid endarterectomy vein patch reconstruction. (In Press). 4. E I K E L B O O M BC, A C K E R S T A F F RGA, H O E N E V E L D H, et al. Benefits of carotid patching: a randomized study. J Vase Sttrg 1988:7:240-2471 5. RILES TS, L A M P A R E L L O PJ, G I A B G O L A G, et al.
Rupture of the vein patch: a rare complication of carotid endarterectomy. Surget T 1990;107:10-12. 6. B E R N S T E I N E. (Personal CommunicationL Ann Sur~o (In Press). 7. C A R N E Y Wl, L I L L Y MP. Intraoperative evaluation of PTFE, Dacron and autogenous vein as carotid patch materials. Ann Vase Sm74 1987;I(5):583-586.
To determine the prevalence, demographics and morbidity of vein patch rupture, the authors polled members of the Western Vascular Society. Forty-eight surgeons (53% of the members) reported an experience with 23,873 carotid operations. A vein patch was used in 1,760 operations (7.4%), and rupture of the patch occurred in 13 patients (0.7%), 10 women and three men. Indications for the patch were a small artery in 10 patients and restenosis in three. Saphenous vein was used for all patches and was harvested from the ankle in 12 patients and from the groin in one patient. All ruptures occurred from a split in the vein patch. Hypertension was present in seven of the 13 patients. None of the ruptures were associated with infection. Two ruptures occurred on the first postoperative day, six on the second day, three on the third day, one on the eighth day, and one on the twenty-first day. Four patients died: airway obstruction (1), hemorrhagic cerebral infarction (1), and myocardial infarction (2) were the causes. Three had a stroke and survived, one had a retinal embolus, and five underwent reoperation without complication. Vein patch of the carotid artery is used infrequently by members of the Western Vascular Society. The incidence of rupture of the patch is low (0.7%), but when it occurs, there is significant mortality (30.7%), and morbidity (30.7%). Patients with a vein patch should be observed in the hospital for three days after endarterectomy because rupture demands immediate reoperation. (Ann Vasc Surg 1991;5:71-73).
KEY WORDS: Vein patch angioplasty; rupture, vein patch; carotid endarterectomy; Western Vascular Society; vascular surgery.
Vein patch angioplasty is an accepted technique for closure of the carotid artery after endarterectomy. Rupture of the patch or blowout occurs infrequently. Consequently, most surgeons have little experience with this life-threatening complication. To determine the prevalence, demographics, morbidity, and mortality of vein patch rupture (VPR), the authors surveyed members of the Western Vascular Society. This report is a summary of the results of this survey.
PATIENTS AND METHODS Questionnaires were sent to the 90 vascular surgeons in the Western Vascular Society. Forty-eight surgeons (53%) responded, reporting a collective experience with 23,873 carotid arteries after endarterectomy. One thousand seven hundred sixty patients (7.4%) had saphenous vein patch angioplasty. The surgeons' experience ranged from five to 32 years (mean 16 years). Rupture of the vein patch occurred in 13 patients (0.7%).
Presented at the Western Vascular Society Meeting, Coronado, California, January 25-28, 1990. Reprint requests: Roy L. Tawes, Jr., MD, 101 S. San Mateo Drive #112, San Mateo, California 94401.
Demographics
Ten patients with a ruptured patch were female (77%) and three were male. Their ages ranged from 71
VEIN PATCH RUPTURE
72
65 to 80 years (mean 73 years). The indication for a vein patch angioplasty was a small internal carotid artery in 10 (-+ 3 mm) and operation for restenosis in three. Saphenous vein was the source of the patch in all 13 patients and was harvested from the ankle in 12 and from the groin in one. In all cases, the vein patch rupture resulted from a split in the saphenous vein. In no case did a suture break or a tie on a tributary unravel. None of the wounds were infected. Postoperative hypertension was present in seven of the 13 patients. In two patients, vein patch rupture occurred on the first postoperative day, in six on the second day, and in three on the third day: There were two late ruptures at eight and 21 days after operation. Mortality and morbidity
Vein patch rupture was associated with a serious complication or death in eight patients (61%). Three patients suffered a major stroke, one developed a retinal hemorrhage (a complication rate of 30.7%). Four patients died, representing a mortality of 30.7%. One died from airway obstruction, two from myocardial infarction and one from hemorrhagic cerebral infarction.
DISCUSSION Patch graft angioplasty has been recommended to obtain better early patency, decrease the risk of postoperative thrombosis, and prevent late restenosis. From conversations with colleagues, it appears that the enthusiasm for patch graft angioplasty following carotid endarterectomy varies regionally and is usually reserved for closure of small internal carotid arteries (ICA) and repair of recurrent stenoses. A review of the literature reveals sparse information, however, regarding the complication of vein patch rupture. Hertzer and associates reported three vein patch ruptures in 433 patients with one stroke [1]. Subsequent communication from the Cleveland Clinic reported an incidence of 0.7% for this complication (N. Hertzer, personal communication, 1990). Hans and colleagues reported no patch graft ruptures in 83 patients [2]. Archie and coworkers reported vein patch rupture in two of 416 for saphenous vein patch reconstructions, an incidence of 0.5% [3]. Archie studied the hemodynamics of vein patch rupture and concluded that saphenous vein diameter is the primary determinant of rupture due to stress. Eikelboom and associates reported one vein patch rupture on the second postoperative day in 67 patients having vein patch angioplasty [4]. The paucity of reports on vein patch rupture suggests that this complication is an unusual occurrence and probably underreported.
ANNALS OF VASCULAR SURGERY
Riles and colleagues will report next year in Surgery on rupture of saphenous vein patch taken from the ankle in three of 75 patients (4%). They have had no ruptures of vein patches harvested from the groin in over 2,000 carotid angioplasties [5]. If vein patch angioplasty gains in popularity, vascular surgeons must be acquainted with this potential complication to avoid high mortality and severe morbidity associated with this catastrophic event. Vein patch rupture or blowout is a dramatic event, presenting with an expanding hematoma in the operativ e site and associated with airway distress, neurologic deficit or hemodynamic deterioration. Emergency treatment requires prompt intubation. If intubation cannot be performed with a large hematoma present, it may be necessary to open the wound and apply direct pressure over the vein patch rupture. All 13 blowouts resulted from a split in the saphenous vein. Suture repair is not advised and, in our opinion, the artery should be repaired with a synthetic patch. Surgeons in their attempt to decrease the restenosis rate by using vein patch angioplasty may be subjecting patients to a potential complication in a small number of cases. Restenosis is usually asymptomatic and is associated with a low stroke rate [6]. With current techniques using magnifying loups, many small internal carotid arteries can be closed safely without a patch. It could be argued that vein patch angioplasty should be used selectively not routinely. This study does not address the issue of whether patches should be used at all and, if used, what is the best patch material. Carney and Lilly evaluated patch material, but did not address the problem of vein patch rupture [7]. The purpose of this report is to focus attention on an infrequent, but severe complication of vein patch angioplasty. It is generally accepted that small arteries and operations for restenosis require a patch. A prospective randomized study is needed to determine the best patch material to prevent blowout. An additional consideration involves reimbursement based on diagnosis-related groups (DRGs). In the present climate of concern regarding hospital costs and length of stay, our data justify not discharging the patient undergoing carotid endarterectomy with a vein patch until the third or fourth postoperative day. In this study, six of the 13 vein patch ruptures occurred on the second postoperative day; in three cases after intravenous nitroprusside had been weaned and the patient experienced significant recurrent hypertension. Approximately 80,000 carotid endarterectomies were performed in 1988. If 7.4% of the surgeons used a vein patch, this represents an additional approximate cost of $5.92 million to observe 5,920 patients an extra day, assuming a cost basis of $1,000/day, which may be a low estimate. If the incidence of vein patch
VOLUME 5 NO 1 - 1991
VEIN PATCH RUPTURE
rupture is 0.7%, 414 patients annually might rupture their vein patch, suffering a 61% serious complication rate. Perhaps one extra day of observation would decrease this projected mortality and morbidity.
CONCLUSIONS
In summary, members of the Western Vascular Society use vein patch angioplasty infrequently (7.4%). The incidence of vein patch rupture is low (0.7%) but is associated with a significant mortality (30.7%) and morbidity (30.7%). Patients with a carotid vein patch require careful control of hypertension and observation in the hospital for at least three days after carotid endarterectomy. Most vein patch ruptures occur one to three days after operation and require immediate reoperation. The purpose of this paper is to alert vascular surgeons to this unusual, but hazardous complication.
m m m
73
REFERENCES
1. H E R T Z E R NR, B E V E N EG, O ' H A R A PJ, et al. A pro-
spective study of vein patch angioplasty during carotid endarterectomy. Ann Surg 1987;206:628-635. 2. H A N S SS, G I R I S H K U M A R H, H A N S B. Vein patch grafts and carotid endarterectomy. Arch Surg 1987;122:1134-1138. 3. A R C H I E JP Jr, G R E E N JJ. Saphenous vein rupture pressure, rupture stress and carotid endarterectomy vein patch reconstruction. (In Press). 4. E I K E L B O O M BC, A C K E R S T A F F RGA, H O E N E V E L D H, et al. Benefits of carotid patching: a randomized study. J Vase Sttrg 1988:7:240-2471 5. RILES TS, L A M P A R E L L O PJ, G I A B G O L A G, et al.
Rupture of the vein patch: a rare complication of carotid endarterectomy. Surget T 1990;107:10-12. 6. B E R N S T E I N E. (Personal CommunicationL Ann Sur~o (In Press). 7. C A R N E Y Wl, L I L L Y MP. Intraoperative evaluation of PTFE, Dacron and autogenous vein as carotid patch materials. Ann Vase Sm74 1987;I(5):583-586.
