Surgical Treatment of Residual Distal Intimal Flap during Eversion Carotid Endarterectomy

Background: Eversion carotid endarterectomy (ECEA) is an effective surgical technique for the treatment of internal carotid artery (ICA) stenosis. However, a residual distal intimal flap may determine a higher rate of neurological complications. The treatment of DIF may be challenging, and no definitive approach has been described. We describe a simple surgical option for the treatment of DIF. Methods: After internal ECEA has been performed, stitches are positioned at the side of intimal flap. Suture sequence is performed from internal-external-external-internal artery wall including the everted ICA, maintaining the suture thread inside the vessel. Once the ICA is correctly repositioned, the suture thread is pulled out. Once the standard carotid anastomosis has been performed, the flap is finally tacked. Results: Fifteen patients have undergone surgical repair of DIF with the modified technique. No patients developed neurological complications after the surgical procedure, and all patients are still alive at last follow-up visit. Conclusions: This simple technique seems a safe and feasible surgical option to correct DIF, avoiding challenging surgical procedures that may increase operative and clamping time.