Clinical ResearchRedo Surgery or Carotid Stenting for Restenosis after Carotid Endarterectomy: Results of Two Different Treatment Strategies
Introduction
Since DeBakey performed the first thromboendarterectomy of the internal carotid artery (ICA), carotid endarterectomy (CEA) has become one of the most frequently performed vascular surgical procedures as secondary prophylaxis for carotid stenosis–associated stroke.1 Currently, in the United States an estimated 170,000 CEA procedures are performed each year.2 The role of CEA has been well documented in large randomized trials, whereas carotid artery stenting (CAS) has recently emerged as a less invasive treatment alternative, whose final role in carotid revascularization will be determined on the basis of ongoing randomized trials.3
However, in the case of carotid restenosis (CR) after CEA considerable controversy exists about clinical significance, natural history, threshold for management, and the appropriate choice of treatment. As reported in a consensus statement from the American Heart Association and the European Stroke Organization,4 CAS so far should be offered to a limited group of high-risk patients, such as patients with severe cardiopulmonary comorbidities, prior neck irradiation, inaccessible lesions above the C2 level, and post-CEA recurrent stenosis.5, 6 Despite early promising results of CAS, questions remained concerning the long-term durability of this endovascular treatment. Reports suggesting a low incidence of CAS-related in-stent restenosis (ISR) were largely derived from studies with small sample sizes and short follow-up periods. Other studies reported poor durability after stenting for recurrent artery stenosis, and still others reported good long-term results after CAS in high-risk patients.7, 8, 9, 10, 11, 12 The purpose of this study was to examine procedural indications, techniques, and midterm treatment outcomes of CEA and CAS for postendarterectomy stenosis in a single-center setting.
Section snippets
Patients and Methods
The records of patients treated for CR were systematically reviewed retrospectively concerning past medical history, symptoms at presentation, atherosclerotic risk factors, procedural details of carotid stenosis repair, duplex ultrasound scanning results, and intraprocedural and postprocedural complications. At 6 weeks, 6 months, and 1 year postoperatively all patients were invited for regular clinical and duplex ultrasound examinations of the extracranial carotid artery at our outpatient
Patient Demographic Data
There was no difference in age in the CEA group compared to the CAS group (mean ages 63.97 and 64.9 years, respectively). Incidence rates of atherosclerotic risk factors and comorbidity were similar in the groups (Table I). There were 39 right- and 47 left-sided CRs treated with similar distribution in the two groups. In 53 cases (61.6%) the patients were on statin therapy. Seventeen patients in the CEA group and 16 patients in the CAS group received no statin prior to diagnosis of CR; the
Discussion
The treatment of CEA and CAS in the management of postendarterectomy CR is of current interest. Reliable data concerning the incidence of CR after CEA are derived from the Asymptomatic Carotid Atherosclerosis Study (ACAS) follow-up study. Moore et al.13 reported incidence rates of 7.6% for early CR (3-18 months) and 1.9% for late CR (18-60 months). The etiology of early and late CR might be of considerable difference. Whereas early CR is most likely secondary to myointimal hyperplasia, late CR
Conclusion
Our data show that CAS in the treatment of CR is feasible and safe. When CAS is contraindicated, CEA remains an alternative treatment option, with acceptable stroke risk. The risk of cranial nerve damage in reoperation might be overestimated.
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