Elsevier

Annals of Vascular Surgery

Volume 24, Issue 2, February 2010, Pages 190-195
Annals of Vascular Surgery

Clinical Research
Redo Surgery or Carotid Stenting for Restenosis after Carotid Endarterectomy: Results of Two Different Treatment Strategies

https://doi.org/10.1016/j.avsg.2009.07.002Get rights and content

Background

We evaluated retrospectively early and midterm results of conventional redo surgery and carotid stent–assisted angioplasty (CAS) in the treatment of carotis restenosis (CR) after carotid endarterectomy (CEA).

Methods

From January 1989 to April 2007, 79 consecutive patients (61 male, median age 65 years, range 51–82) were treated for CR. Seven patients were treated for bilateral CR, accounting for 86 reconstructions, 41 CEAs, and 45 CAS procedures. Fifty (58.1%) CRs were asymptomatic, and 36 (41.9%) CRs were symptomatic. Treatment for CR was recommended for any stenosis >70% based on duplex ultrasound imaging with a peak systolic flow of >200 cm/sec.

Results

There was no difference in age in the two groups. The incidence of atherosclerotic risk factors and comorbidity was similar in the two groups. All patients received aspirin as basic medical treatment, and 53 patients (61.6%) were on statin therapy. The time period from primary CEA to reoperation or CAS was significantly shorter in the CAS group than in the CEA group (54.1 vs. 85.34 months, p = 0.003). Correspondingly, the proportion of early CR was significantly higher in the CAS group as well (20 vs. 5, p = 0.001). There was no perioperative mortality (30 days) in the two groups. In the CEA group, four neurological complications were seen versus one in the CAS group (p = 0.13). Wound site and cardiac complication rates were significantly higher in the CEA group (p = 0.029) with a median follow-up of 35 months (range 12–190). The overall actuarial survival after 60 months was 83% in the CEA group and 100% in the CAS group (p = 0.87). Freedom from repeat intervention for re-recurrence was 89% in the CEA group and 95% in the CAS group (p = 0.52).

Conclusion

CAS is feasible and safe in treating CR. Furthermore, midterm overall survival and need for treatment of re-recurrence is equal to CEA. However, reoperation is an established option and remains the treatment of choice when contraindications for CAS are evident.

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.

References (25)

Cited by (35)

  • Carotid Artery Endarterectomy versus Carotid Artery Stenting for Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-Analysis

    2018, World Neurosurgery
    Citation Excerpt :

    All 13 studies were real-world studies and comprised 4163 patients.14,24-35 Four studies were assessed as having a low risk of bias,24,25,28,31 and 9 were assessed as having a moderate risk of bias (Table S1).14,26,27,29,30,32-35 Detailed patient and study characteristics are presented in Table 1.

  • A Propensity Matched Comparison for Open and Endovascular Treatment of Post-carotid Endarterectomy Restenosis

    2018, European Journal of Vascular and Endovascular Surgery
    Citation Excerpt :

    Several studies have addressed the peri-operative and follow-up outcomes of open and endovascular treatment of post-CEA restenosis, showing satisfactory early and late results with both techniques. However, there is a limited number of studies directly comparing the two treatment options,5–7,12–19 and in the majority of these studies CAS was reserved for early hyperplastic lesions, while redo CEA was preferred in patients with late de novo atherosclerotic plaques. In the present study, results of a previous comparative series7 were updated by adding data on the interventions performed in the years following its publication, and attempts were made to make the comparison reliable by adjusting for baseline confounding factors.

  • Prosthetic bypass for restenosis after endarterectomy or stenting of the carotid artery

    2017, Journal of Vascular Surgery
    Citation Excerpt :

    Regarding general complications, myocardial infarction (MI), which is estimated to occur postoperatively in 1.3% of open carotid revascularization,1 has been considered the main drawback of repeated carotid surgery compared with CAS.28 However, previous studies have reported no postoperative MI after open treatment of recurrent carotid stenosis by either CEA or PCB,3,9 and other studies have shown no significant difference in the incidence of MI between open repeated revascularization and CAS.18,19,22 We did not observe any postoperative MI in our series of 66 patients.

View all citing articles on Scopus
View full text