Reinforced double-layer vein patch angioplasty in carotid endarterectomy to mitigate patch aneurysm

Abstract

Carotid endarterectomy with patch angioplasty is standard for symptomatic carotid stenosis. However, prosthetic patches carry a risk of infection, particularly in patients with recent endocarditis. We report the case of a 67-year-old man who presented with central retinal artery occlusion and active mitral valve vegetation and subsequently underwent left carotid endarterectomy using a dual-layer facial vein patch. The harvested facial vein was everted to create a reinforced, double-layered conduit that was used for patch angioplasty, thereby avoiding prosthetic material. The patient awoke neurologically intact and 1-month duplex ultrasound demonstrated no residual stenosis or aneurysmal degeneration. Dual-layer everted cervical vein patches may provide a safe and durable autologous option in high-risk infectious settings.

Carotid endarterectomy (CEA) with patch angioplasty is the standard surgical treatment for carotid stenosis and has been shown to reduce perioperative stroke, thrombosis, and long-term restenosis compared with primary closure.1, 2, 3 Although multiple patch materials—including polytetrafluoroethylene, Dacron, bovine pericardium, and autogenous vein—demonstrate comparable neurologic outcomes in routine practice, prosthetic patch infection, though rare (<1%), can be catastrophic.^1,3,4 Risk factors include bacteremia, immunosuppression, and recent endocarditis, with Staphylococcus and Streptococcus species most commonly implicated.4, 5, 6

Therefore, in patients with active or recent endocarditis, avoidance of prosthetic material during CEA is prudent. The dual-layer everted cervical vein technique provides an autologous alternative with mechanical strength comparable to saphenous vein and favorable long-term outcomes.^7,8 We report successful use of a dual-layer everted facial vein patch during CEA in a patient with recent infective endocarditis. Informed consent was obtained from the patient to disclose individual clinical information for this case report.

Case report

A 67-year-old man with atrial fibrillation (on apixaban), coronary artery disease status postpercutaneous coronary intervention, hypertension, hyperlipidemia, and recent infective endocarditis secondary to dental abscess presented with acute painless left monocular vision loss. Ophthalmologic examination confirmed central retinal artery occlusion. However, brain magnetic resonance imaging showed no acute infarction. Transthoracic echocardiography demonstrated a 1-cm mitral valve vegetation and moderate aortic regurgitation.

The patient's computed tomography angiography revealed moderate atherosclerotic plaque involving the proximal left internal carotid artery (ICA) without large vessel occlusion. (Fig 1). Duplex ultrasound study demonstrated a left ICA peak systolic velocity of 193 cm/s and heterogeneous irregular plaque, consistent with 50% to 69% stenosis. Although the patient presented with symptomatic ipsilateral carotid stenosis, we acknowledge that in the setting of active infective endocarditis, a cardioembolic source of stroke could not be definitively excluded. Therefore, the carotid lesion may have represented a coincidental finding, rather than the sole source of cerebral embolization. After multidisciplinary discussion, the decision was made to proceed with left CEA while avoiding prosthetic material to address all potential embolic sources before cardiac surgery. Preoperative vein mapping was obtained in anticipation of using an autologous vein patch for arterial reconstruction.

Fig 1.

Preoperative axial, sagittal, and coronal computed tomography angiography demonstrating proximal left internal carotid artery plaque, with accompanying schematic illustration.

Through a longitudinal incision along the anterior border of the sternocleidomastoid muscle, the facial vein was identified, ligated, and harvested. The harvested vein was prepared on the back table by passing a fine hemostat through the lumen, grasping the distal end, and pulling it through to evert the vein onto itself, creating a double-layer configuration with endothelium lining both external surfaces (Fig 2).

Fig 2.

Intraoperative steps demonstrating harvest of the facial vein with eversion to use as an autologous patch for carotid endarterectomy. Completion illustration and intraoperative image demonstrate final patch angioplasty and vessel reconstruction.

After systemic heparinization, the ICA, common carotid artery (CCA), and external carotid artery were sequentially clamped and controlled. A longitudinal arteriotomy was made extending from the CCA across the bifurcation into the ICA. An intraluminal shunt was placed to maintain cerebral perfusion during the endarterectomy. The atherosclerotic plaque was carefully elevated from the CCA in the subintimal plane, and dissection was continued distally into the ICA until a smooth, feathered endpoint was achieved with complete plaque removal. The plaque was transected at the CCA level, and eversion endarterectomy of the external carotid artery was then performed by everting the vessel and removing the plaque core to ensure complete clearance of disease from all three vessels. The dual-layer everted facial vein patch was tailored to approximately 3 cm and sewn using running 6-0 polypropylene suture, ensuring each bite incorporated both layers of vein and the arteriotomy edge in standard fashion.

The artery was flushed before completion, and flow was restored to the ICA. Total operative time was approximately 75 minutes, and clamp time was 20 minutes. The patient awoke neurologically intact and continued aspirin, anticoagulation, and intravenous antibiotics pending mitral valve repair. No signs of systemic or local infection were observed throughout the hospital stay. At 1-month follow-up, the patient remained free of infectious complications with complete wound healing and no cervical tenderness or erythema. Duplex ultrasound study demonstrated patent carotid reconstruction with no residual stenosis and no aneurysmal degeneration of the patch repair. The patient later underwent successful mitral valve repair without complications.

Discussion

Prosthetic patch infection after CEA, although uncommon, remains one of the most devastating complications in carotid surgery, with risks of pseudoaneurysm formation, rupture, and fatal hemorrhage.¹ Patients with active bacteremia or recent endocarditis represent a particularly high-risk population for hematogenous seeding of prosthetic material.¹ Staphylococcus and Streptococcus species—common in infective endocarditis—account for the majority of prosthetic patch infections.4, 5, 6 Systematic reviews demonstrate poor outcomes with prosthetic reconstruction in this condition, with high rates of infection or mortality, whereas autologous reconstruction achieves durable freedom from infection.⁴ Therefore, current Society for Vascular Surgery guidelines mandate autologous tissue reconstruction in established infection.¹ Extending this principle to the primary use of autologous materials in patients with active or recent bacteremia undergoing CEA represents a logical extrapolation of these guidelines and reflects sound surgical judgment aimed at preventing rather than treating prosthetic infection.

The dual-layer everted cervical vein technique provides a practical and immediately available autologous option. Unlike saphenous vein harvest, cervical veins are obtained through the same operative field, eliminating the need for a second incision and reducing operative time.^9,10 Preservation of the saphenous vein is valuable particularly in patients with significant atherosclerotic burden who may require future coronary or peripheral bypass procedures. In addition, this approach is cost-neutral and avoids the expense associated with prosthetic or bovine pericardial patches.

Mechanically, the dual-layer configuration addresses concerns regarding the structural integrity of single-layer cervical vein patches. Bench-top testing by Yu et al⁸ demonstrated that everted cervical vein patches have burst strength comparable to conventional saphenous vein patches and substantially greater than single-layer cervical vein. Although dedicated animal studies directly comparing cervical and saphenous veins as carotid patch materials are lacking, several experimental models have successfully used jugular veins for carotid reconstruction, supporting the biological compatibility of cervical veins in the arterial circulation.^11,12 Clinical experience with everted cervical vein patches has demonstrated stroke-free survival exceeding 95% and freedom from recurrent stenosis greater than 82% at up to 6 years.⁷ By everting the vein onto itself, the technique creates a reinforced construct that may mitigate the risk of late patch dilation and aneurysmal degeneration while maintaining favorable handling characteristics.

Aneurysmal degeneration remains a theoretical concern with any vein patch. Saphenous vein patches have demonstrated early geometric dilation, although true aneurysm formation requiring intervention is rare.^13,14 Reported pseudoaneurysms have more commonly involved saphenous rather than cervical vein patches.^14,15 The dual-layer configuration may provide additional resistance to dilation compared with single-layer vein, though robust comparative long-term data are lacking.

A limitation of this report is the short postoperative follow-up of 1 month, which is insufficient to assess long-term durability or the risk of aneurysmal degeneration. In addition, the theoretical advantages of the inverted double-layer vein patch in reducing infection-related complications are extrapolated from studies performed in noninfected CEA populations and have not been specifically validated in patients with active infection or infective endocarditis. Continued surveillance and larger studies with extended follow-up are needed to better define the long-term performance of this technique, both in routine and infected settings.

This case illustrates that dual-layer everted facial vein patch angioplasty can provide safe, durable carotid reconstruction in patients with recent infective endocarditis while avoiding prosthetic material. In selected high-risk infectious settings—including bacteremia, endocarditis, or contaminated trauma—this technique represents a valuable addition to the vascular surgeon's armamentarium. Prospective studies with extended follow-up are warranted to further define long-term durability and comparative outcomes.

Funding

No outside funding was used for this report.

Disclosures

The authors report no conflicts of interest.