Patch angioplasty versus primary closure for carotid endarterectomy

Saritphat Orrapin; Thoetphum Benyakorn; Boonying Siribumrungwong; Kittipan Rerkasem

doi:10.1002/14651858.CD000160.pub4

Cochrane Database of Systematic Reviews

Patch angioplasty versus primary closure for carotid endarterectomy

Information

DOI:

https://doi.org/10.1002/14651858.CD000160.pub4 Copy DOI

Database:

Cochrane Database of Systematic Reviews

Version published:

03 August 2022see what's new

Type:

Intervention

Stage:

Review

Cochrane Editorial Group:

Cochrane Stroke Group

Copyright:

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

Saritphat Orrapin

Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
Thoetphum Benyakorn

Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
Boonying Siribumrungwong

Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
Kittipan Rerkasem

Correspondence to: Environmental - Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand

[email protected]

Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Contributions of authors

SO, TB, KR: refined the protocol, performed searches, selected studies for inclusion, extracted and entered data, and wrote the review.

BS, KR: refined the protocol, co‐ordinated the project, and commented on the design of the protocol and on the final manuscript.

Sources of support

Internal sources

Chiang Mai University, Thailand

This study was partially supported by Chiang Mai University

External sources

No sources of support provided

Declarations of interest

SO: none known.

TB: none known.

BS: none known.

KR: none known.

Acknowledgements

We would like to thank Dr Rick Bond, Professor Ali AbuRahma, Professor Ross Naylor and Professor Peter M Rothwell for their contribution to previous versions of this review. We also thank Hazel Fraser for searching the Cochrane Stroke Group trials register and for providing regular updates of newly identified trials; and Joshua Cheyne for searching the Cochrane Central Register of Controlled Trials (CENTRAL). This study was supported by the Research group in surgery, Faculty of Medicine, Thammasat University. This study was partially supported by Chiang Mai University.

Ongoing trials

If any reader is aware of any randomised trials that we have omitted, please contact Dr Saritphat Orrapin.

Version history

Published

Title

Stage

Authors

Version

2022 Aug 03

Patch angioplasty versus primary closure for carotid endarterectomy

Review

Saritphat Orrapin, Thoetphum Benyakorn, Boonying Siribumrungwong, Kittipan Rerkasem

https://doi.org/10.1002/14651858.CD000160.pub4

2009 Oct 07

Patch angioplasty versus primary closure for carotid endarterectomy

Review

Kittipan Rerkasem, Peter M Rothwell

https://doi.org/10.1002/14651858.CD000160.pub3

2009 Jul 08

Patch angioplasty versus primary closure for carotid endarterectomy

Review

Richard Bond, Kittipan Rerkasem, Ali F AbuRahma, A Ross Naylor, Peter M Rothwell

https://doi.org/10.1002/14651858.CD000160.pub2

1996 May 17

Patch angioplasty versus primary closure for carotid endarterectomy

Review

C Counsell, R Salinas, C Warlow, R Naylor

https://doi.org/10.1002/14651858.CD000160

Differences between protocol and review

For this review update, we did not plan to carry out sensitivity analyses: the current authors considered them unreasonably critical, as the previous version of this review found no evidence of a difference between the trials with different allocation techniques.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

PICOs

Population

Intervention

Comparison

Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 1: Any stroke (fatal or non‐fatal; contralateral, ipsilateral or brainstem; haemorrhage or infarct)

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Analysis 1.2

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 2: Stroke‐related death

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Analysis 1.3

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 3: Ipsilateral stroke (fatal or non‐fatal; haemorrhage or infarct)

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Analysis 1.4

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 4: Death from all causes

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Analysis 1.5

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 5: Any stroke or death

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Analysis 1.6

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 6: Occlusion of operated artery

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Analysis 1.7

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 7: Rupture or haemorrhage of endarterectomy site

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Analysis 1.8

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 8: Infection of endarterectomy site

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Analysis 1.9

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 9: Cranial nerve palsy

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Analysis 1.10

Comparison 1: Patch versus primary closure: outcomes within 30 days of operation, Outcome 10: Complications requiring reintervention

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Analysis 2.1

Comparison 2: Patch versus primary closure: outcomes during long‐term follow‐up, including events during first 30 days, Outcome 1: Any stroke (fatal or non‐fatal; contralateral, ipsilateral or brainstem; haemorrhage or infarct)

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Analysis 2.2

Comparison 2: Patch versus primary closure: outcomes during long‐term follow‐up, including events during first 30 days, Outcome 2: Stroke‐related death

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Analysis 2.3

Comparison 2: Patch versus primary closure: outcomes during long‐term follow‐up, including events during first 30 days, Outcome 3: Ipsilateral stroke (fatal or non‐fatal; haemorrhage or infarct)

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Analysis 2.4

Comparison 2: Patch versus primary closure: outcomes during long‐term follow‐up, including events during first 30 days, Outcome 4: All‐cause death

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Analysis 2.5

Comparison 2: Patch versus primary closure: outcomes during long‐term follow‐up, including events during first 30 days, Outcome 5: Any stroke or death

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Analysis 2.6

Comparison 2: Patch versus primary closure: outcomes during long‐term follow‐up, including events during first 30 days, Outcome 6: Restenosis (> 50%) or occlusion of operated artery

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Summary of findings 1. Main comparison of patch angioplasty versus primary closure

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Patch angioplasty versus primary closure following carotid endarterectomy
Patient or population: people undergoing carotid endarterectomy, whether initial indication for endarterectomy was symptomatic or asymptomatic carotid disease Settings: hospitals with carotid centres Intervention: any type of patch angioplasty Comparison: primary closure
	Assumed risk	Corresponding risk
	Primary closure	Patch angioplasty
Any stroke (fatal or non‐fatal; contralateral, ipsilateral or brainstem; haemorrhage or infarct) within 30 days of operation	Total		OR 0.57 (0.31, 1.03)	1769 (8 studies)	⊕⊝⊝⊝ Very low^a,b	No studies could be blinded for surgeons due to the nature of the intervention.
	32 per 1000	19 per 1000	OR 0.57 (0.31, 1.03)	1769 (8 studies)	⊕⊝⊝⊝ Very low^a,b
Ipsilateral stroke (fatal or non‐fatal; haemorrhage or infarct) within 30 days of operation	Total		OR 0.31 (0.15, 0.63)	1201 (7 studies)	⊕⊝⊝⊝ Very low^a,b	No studies could be blinded for surgeons due to the nature of the intervention.
	79 per 1000	14 per 1000	OR 0.31 (0.15, 0.63)	1201 (7 studies)	⊕⊝⊝⊝ Very low^a,b
Occlusion of the operated artery within 30 days of operation	Total		OR 0.18 (0.08, 0.41)	1435 (7 studies)	⊕⊕⊝⊝ Low^a,b,d	No studies could be blinded for surgeons due to the nature of the intervention.
	31 per 1000	5 per 1000	OR 0.18 (0.08, 0.41)	1435 (7 studies)	⊕⊕⊝⊝ Low^a,b,d
Any stroke (fatal or non‐fatal; contralateral, ipsilateral or brainstem; haemorrhage or infarct) during long‐term follow‐up, including events during first 30 days	Total		OR 0.49 (0.27, 0.90)	1332 (7 studies)	⊕⊝⊝⊝ Very low^a,b	No studies could be blinded for surgeons due to the nature of the intervention.
	46 per 1000	23 per 1000	OR 0.49 (0.27, 0.90)	1332 (7 studies)	⊕⊝⊝⊝ Very low^a,b
Ipsilateral stroke (fatal or non‐fatal; haemorrhage or infarct) during long‐term follow‐up, including events during first 30 days	Total		OR 0.32 (0.16, 0.63)	1141 (6 studies)	⊕⊝⊝⊝ Very low^a,b	No studies could be blinded for surgeons due to the nature of the intervention.
	48 per 1000	16 per 1000	OR 0.32 (0.16, 0.63)	1141 (6 studies)	⊕⊝⊝⊝ Very low^a,b
Any stroke or death during long‐term follow‐up, including events during first 30 days	Total		OR 0.59 (0.42, 0.84)	1019 (6 studies)	⊕⊝⊝⊝ Very low^a,b	No studies could be blinded for surgeons due to the nature of the intervention.
	296 per 1000	130 per 1000	OR 0.59 (0.42, 0.84)	1019 (6 studies)	⊕⊝⊝⊝ Very low^a,b
Restenosis (> 50%) or occlusion of operated artery during long‐term follow‐up, including events during first 30 days	Total		OR 0.24 (0.17, 0.34)	1719 (8 studies)	⊕⊕⊝⊝ Low^a,c,d	No studies could be blinded for surgeons due to the nature of the intervention.
	138 per 1000	43 per 1000	OR 0.24 (0.17, 0.34)	1719 (8 studies)	⊕⊕⊝⊝ Low^a,c,d
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels for serious risk of bias concerns as studies did not blind surgeons and participants and did not report blinding of outcome assessment (AbuRahma 1996; Al‐Rawi 2006; De Vleeschauwer 1987; Eikelboom 1988; İyigün 2019; Katz 1994; Lord 1989; Mannheim 2005; Myers 1994; Pratesi 1986; Ranaboldo 1993); and due to selective reporting (AbuRahma 1996 Al‐Rawi 2006; De Vleeschauwer 1987; Eikelboom 1988; İyigün 2019; Katz 1994; Lord 1989; Mannheim 2005; Myers 1994; Pratesi 1986; Ranaboldo 1993), incomplete outcome data (Eikelboom 1988; Katz 1994; Myers 1994; Ranaboldo 1993), and inadequate allocation concealment and random sequence generation (De Vleeschauwer 1987; Katz 1994). ^bDowngraded one level for imprecision due to wide confidence intervals (low event rates) and lack of events (De Vleeschauwer 1987; Eikelboom 1988 Katz 1994; Lord 1989). ^cDowngraded one level for inconsistency due to true heterogeneity according to the I² statistic and P value, confidence interval overlap, difference in point estimate, and between‐study variance (Analysis 2.6). ^dUpgraded one level for large effects (Analysis 1.6).

Summary of findings 1. Main comparison of patch angioplasty versus primary closure

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Table 1. Number of cases lost to follow‐up

Study	Total participants	Total operations	Lost to FU at 30 days		Lost to FU at end		Number of exclusions	Cross‐over: patch to primary	Cross‐over: primary to patch
Study	Total participants	Total operations	Patch angioplasty	Primary closure	Patch angioplasty	Primary closure	Number of exclusions	Cross‐over: patch to primary	Cross‐over: primary to patch
AbuRahma 1996	357	399	0	0	0	0	4	0	0
Al‐Rawi 2006l	315	328	0	0	7	8	10	Data not available	Data not available
Eikelboom 1988	126	129	0	0	10 participants lost to Doppler FU but not clinical FU	7 to Doppler FU but not clinical FU	0	3	3
İyigün 2019	137	137	Data not available	Data not available	Data not available	Data not available	Data not available	Data not available	Data not available
Katz 1994	87	100	0	0	5	7	0	0	0
Lord 1989	123	140	0	0	0	0	4	Between 0 and 4	Between 0 and 4
Mannheim 2005	404	422	0	0	Data not available	Data not available	Data not available	0	0
Myers 1994	136 (109 after exclusion of 27 people undergoing obligatory vein patching)	152 (122 analysed, as 30 had obligatory vein patches)	0	0	6	8	30 operations had obligatory vein patch closure and 16 participants had both sides done (total 46)	0	0
Pratesi 1986	90	100	Data not available	Data not available	Data not available	Data not available	Data not available	Data not available	Data not available
Ranaboldo 1993	199	213	0	0	5	12	0	0	0 at 30‐day FU but 4 at 1‐year FU
De Vleeschauwer 1987	126	174	0	0	Data not available	Data not available	0	0	0
FU: follow‐up

Table 1. Number of cases lost to follow‐up

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Comparison 1. Patch versus primary closure: outcomes within 30 days of operation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Any stroke (fatal or non‐fatal; contralateral, ipsilateral or brainstem; haemorrhage or infarct) Show forest plot	8	1769	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.57 [0.31, 1.03]

1.1.1 Venous patch	3	346	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.38 [0.08, 1.72]
1.1.2 Synthetic patch	3	837	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.23 [0.50, 3.07]
1.1.3 Synthetic or venous patch	2	586	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.29 [0.11, 0.74]
1.2 Stroke‐related death Show forest plot	7	1441	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.47 [0.05, 4.56]

1.2.1 Venous patch	3	346	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.91 [0.06, 14.73]
1.2.2 Synthetic patch	2	509	Peto Odds Ratio (Peto, Fixed, 95% CI)	Not estimable
1.2.3 Synthetic or venous patch	2	586	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.13 [0.00, 6.46]
1.3 Ipsilateral stroke (fatal or non‐fatal; haemorrhage or infarct) Show forest plot	7	1201	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.31 [0.15, 0.63]

1.3.1 Venous patch	3	349	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.39 [0.09, 1.75]
1.3.2 Synthetic patch	1	100	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.53 [0.05, 5.19]
1.3.3 Synthetic or venous patch	3	752	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.27 [0.11, 0.62]
1.4 Death from all causes Show forest plot	9	1869	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.62 [0.18, 2.09]

1.4.1 Venous patch	3	346	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.79 [0.18, 17.57]
1.4.2 Synthetic patch	3	837	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.14 [0.00, 7.15]
1.4.3 Synthetic or venous patch	3	686	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.48 [0.10, 2.24]
1.5 Any stroke or death Show forest plot	8	1769	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.58 [0.33, 1.01]

1.5.1 Venous patch	3	346	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.55 [0.13, 2.25]
1.5.2 Synthetic patch	3	837	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.10 [0.45, 2.69]
1.5.3 Synthetic or venous patch	2	586	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.34 [0.15, 0.78]
1.6 Occlusion of operated artery Show forest plot	7	1435	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.18 [0.08, 0.41]

1.6.1 Venous patch	2	255	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.12 [0.01, 1.99]
1.6.2 Synthetic patch	2	428	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.33 [0.06, 1.95]
1.6.3 Synthetic or venous patch	3	752	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.16 [0.06, 0.42]
1.7 Rupture or haemorrhage of endarterectomy site Show forest plot	9	2031	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.24 [0.61, 2.54]

1.7.1 Venous patch	3	429	Peto Odds Ratio (Peto, Fixed, 95% CI)	6.86 [0.14, 346.63]
1.7.2 Synthetic patch	3	850	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.92 [0.39, 2.14]
1.7.3 Synthetic or venous patch	3	752	Peto Odds Ratio (Peto, Fixed, 95% CI)	2.32 [0.56, 9.57]
1.8 Infection of endarterectomy site Show forest plot	7	1563	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.38 [0.09, 1.54]

1.8.1 Venous patch	3	429	Peto Odds Ratio (Peto, Fixed, 95% CI)	Not estimable
1.8.2 Synthetic patch	2	522	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.38 [0.09, 1.54]
1.8.3 Synthetic or venous patch	2	612	Peto Odds Ratio (Peto, Fixed, 95% CI)	Not estimable
1.9 Cranial nerve palsy Show forest plot	5	1184	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.59 [0.30, 1.19]

1.9.1 Venous patch	1	126	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.77 [0.17, 3.50]
1.9.2 Synthetic patch	2	522	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.75 [0.24, 2.35]
1.9.3 Synthetic or venous patch	2	536	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.43 [0.15, 1.25]
1.10 Complications requiring reintervention Show forest plot	7	1281	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.35 [0.16, 0.79]

1.10.1 Venous patch	3	429	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.98 [0.06, 15.64]
1.10.2 Synthetic patch	1	100	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.53 [0.05, 5.19]
1.10.3 Synthetic or venous patch	3	752	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.29 [0.12, 0.73]

Comparison 1. Patch versus primary closure: outcomes within 30 days of operation

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Comparison 2. Patch versus primary closure: outcomes during long‐term follow‐up, including events during first 30 days

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Any stroke (fatal or non‐fatal; contralateral, ipsilateral or brainstem; haemorrhage or infarct) Show forest plot	7	1332	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.49 [0.27, 0.90]

2.1.1 Venous patch	3	346	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.42 [0.14, 1.30]
2.1.2 Synthetic patch	2	400	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.95 [0.59, 6.45]
2.1.3 Synthetic or venous patch	2	586	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.25 [0.10, 0.62]
2.2 Stroke‐related death Show forest plot	6	1019	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.27 [0.05, 1.60]

2.2.1 Venous patch	3	346	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.46 [0.05, 4.52]
2.2.2 Synthetic patch	1	87	Peto Odds Ratio (Peto, Fixed, 95% CI)	Not estimable
2.2.3 Synthetic or venous patch	2	586	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.13 [0.01, 2.04]
2.3 Ipsilateral stroke (fatal or non‐fatal; haemorrhage or infarct) Show forest plot	6	1141	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.32 [0.16, 0.63]

2.3.1 Venous patch	3	429	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.42 [0.12, 1.47]
2.3.2 Synthetic patch	1	100	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.53 [0.05, 5.19]
2.3.3 Synthetic or venous patch	2	612	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.25 [0.10, 0.62]
2.4 All‐cause death Show forest plot	7	1332	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.78 [0.54, 1.12]

2.4.1 Venous patch	3	346	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.80 [0.45, 1.42]
2.4.2 Synthetic patch	2	400	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.90 [0.39, 2.05]
2.4.3 Synthetic or venous patch	2	586	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.69 [0.38, 1.26]
2.5 Any stroke or death Show forest plot	6	1019	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.59 [0.42, 0.84]

2.5.1 Venous patch	3	346	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.69 [0.40, 1.20]
2.5.2 Synthetic patch	1	87	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.62 [0.23, 1.66]
2.5.3 Synthetic or venous patch	2	586	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.51 [0.30, 0.86]
2.6 Restenosis (> 50%) or occlusion of operated artery Show forest plot	8	1719	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.24 [0.17, 0.34]

2.6.1 Venous patch	3	429	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.34 [0.17, 0.66]
2.6.2 Synthetic patch	3	678	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.46 [0.22, 0.98]
2.6.3 Synthetic or venous patch	2	612	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.15 [0.09, 0.25]

Comparison 2. Patch versus primary closure: outcomes during long‐term follow‐up, including events during first 30 days

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Patch angioplasty versus primary closure for carotid endarterectomy

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