Page 84 - BH-3-1

Brain & Heart Bovine pericardial patching in CEA

hemostasis time was longer due to anastomotic bleeding. artery stenosis and CAD are individually important risk
7,24
The ESVS 2023 clinical practice guideline supported factors in the treatment of the other, so selective cardiac
routine patch closure with class 1 recommendation and testing may be very important in patients undergoing
level 1 evidence, but no significant difference was observed CEA. Actually, most myocardial infarction often occur in
33
between patch material. The 2023 ESVS and the 2022 the perioperative period, even though no cardiac events
34
25
25
SVS guidelines recommended that the selection of patch occurred in the perioperative period in this study. As an
7
material should be considered by the operating surgeon for open surgery requiring general anesthesia, CEA places
patients undergoing CEA. greater demands and creates a greater burden on the heart,
resulting in a higher incidence of perioperative myocardial
Among retrospectively reviewed literature, only two 35
randomized controlled trials had attempted at comparing infarction in CEA compared with CAS.
BP patch with synthetic patches, which did not yield Patch infection is a very rare but serious complication
statistically significant difference. 26,27 Nevertheless, the BP of CEA surgery, with most cases noted following the
patch was probably associated with lower risk for long- usage of synthetic patches. It may present as swelling,
36
term restenosis compared with the synthetic patch (4.0% pseudoaneurysms, or draining sinuses, and occurs in
vs. 7.6%) in a real-world study; however, the duration of <1% of cases. 36,37 Due to its low incidence, the exact
the follow-up in the BP patch arm was shorter. Moreover, risk factors are not well elucidated. However, since it is
23
the randomized controlled trial by Marien et al. showed closely associated with surgical site infection, conditions
27
that bleeding from the suture lines was significantly lesser such as perioperative hematoma, diabetes mellitus, and
37
in the BP patch arm vs. synthetic patch arm (14% vs. immunosuppression may increase its risk. In this study,
55%, p < 0.001). A network meta-analysis of CEA closure no infection-related cases occurred, highlighting the anti-
techniques concluded that BP or PTFE patching is associated infection ability of BP patch.
with a lower short-term incidence and delayed onset of Only one patient underwent re-exploration hematoma
adverse outcomes following CEA, making them potentially during the perioperative period. To prevent thrombosis,
better choice compared to other closure techniques. 24 patients routinely need to use antiplatelet drugs, but this
The short- and long-term results of BP patching for undoubtedly increases the risk of hematoma. Morales
vascular applications have been excellent, with only Gisbert et al. summarized the risk factors associated
38
7% restenosis rate after 5-year follow-up as reported by with hematoma in their single-center retrospective study,
28
26
Ladowski et al. Stone et al. reviewed studies on the including clopidogrel use, post-operative hypertension,
BP patch, and found that restenosis rate was between 1% pre-operative anticoagulant use, and prosthetic patch. It
and 10% during the 1- to 5-year follow-up periods. Our has also been found that the use of dual antiplatelet therapy
results showed that the restenosis rate with the BP patch (relative risk [RR] = 11.84, p = 0.002) and anticoagulation
was 3.5% (2/57) at the 12-month follow-ups. The incidence (RR = 8.604, p = 0.02) before CEA surgery is significantly
39
of restenosis was slightly higher than that reported in a associated with the occurrence of severe hematoma.
previous study; however, we believe that it was biased In these cases, more careful hemostasis may be required
by the small sample size. Both groups were satisfactory during surgery, or even the use of drainage tubes should be
in terms of the vascular events, further supporting the considered to prevent more serious consequences.
application of the patch during CEA. This study has several limitations. First, there is a lack of
Only one cardiac event occurred within 6 months after study power to detect the differences in stroke or mortality
surgery and the patient had a good prognosis. It has long rates due to the incidence of adverse events. Second, the
been known that there is a close relationship between follow-up duration was not sufficiently long, which could
atherosclerosis-related carotid artery stenosis and coronary have introduced bias to some extent. Third, this study
31
artery disease. 29,30 A real-world study by Arinze et al. also spanned a long period, and the COVID-19 pandemic
found that the incidence of myocardial infarction was 0.5% seriously stifled the progress of the entire study. Fourth,
and 1.1% at 30 and 90 days after CEA, respectively. The because several patients chose to do primary closure
incidence of cardiac events in the current study was about 1% without a patch, the enrollment became slow during the
at 6 months, which is similar to Arinze et al.’s study. Since consent acquisition process.
31
cardiovascular and cerebrovascular diseases and coronary
heart disease share similar risk factors, screening for both 5. Conclusion
32
31
is necessary. Arinze et al. had attempted but failed to The BP patch shows no significant difference compared to
find the relationship between high-intensity statins and the polyurethane patch available on the market in terms
myocardial infarction and stroke after CEA. Both carotid of the restenosis rate or adverse clinical events during

Volume 3 Issue 1 (2025) 6 doi: 10.36922/bh.4568