Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy

Abstract

Introduction Outcomes for patients undergoing intervention for restenosis after prior ipsilateral carotid endarterectomy (CEA) in the era of carotid stenting (CAS) are unclear. We compared perioperative results and durability of CAS versus CEA in patients with symptomatic or asymptomatic restenosis after prior CEA and investigated the risk of re-intervention compared to primary procedures. Methods Patients undergoing CAS and CEA for restenosis between January 2003 and March 2012 were identified within the Vascular Study Group of New England (VSGNE) database.Endpoints included any stroke, death or myocardial infarction (MI) within 30 days, cranial nerve injury at discharge and restenosis ≥70% at 1-year follow-up. Multivariable logistic regression was done to identify whether prior ipsilateral CEA was an independent predictor for adverse outcome. Results Out of 9305 CEA procedures, 212 patients (2.3%) underwent redo-CEA (36% symptomatic). Of 663 CAS procedures, 220 patients (33%) underwent CAS after prior ipsilateral CEA (31% symptomatic). Demographics of patients undergoing redo-CEA were comparable to patients undergoing CAS after prior CEA. Stroke/death/MI rates were statistically similar between redo-CEA vs CAS after prior CEA in both asymptomatic (4.4% vs 3.3%, P=0.8) and symptomatic patients (6.6% vs 5.8%, P=1.0). No significant difference in restenosis ≥70% was identified between redo-CEA and CAS after prior CEA (5.2% vs. 3.0%, P = 0.5). Redo-CEA vs primary CEA had increased stroke/death/MI rate in both symptomatic (6.6% vs 2.3%, P=0.05) and asymptomatic patients 4.4% vs 1.7%, P=0.03). Prior ipsilateral CEA was an independent predictor for stroke/death/MI among all patients undergoing CEA (OR 2.1, 95% CI 1.3 – 3.5). No difference in cranial nerve injury was identified between redo-CEA and primary CEA (5.2% vs 4.7%, P=0.8). Conclusions In the VSGNE, CEA and CAS showed statistically equivalent outcomes in asymptomatic and symptomatic patients treated for restenosis after prior ipsilateral CEA.However, regardless of symptom status, the risk of re-intervention was increased compared to patients undergoing primary CEA.

Stenting Versus Endarterectomy for Restenosis Following Prior Ipsilateral Carotid Endarterectomy

“…Sensitivity analysis was performed by excluding patients from the largest study. 16 In this subset analysis, a similar effect size and direction was identified for both primary and secondary endpoints compared with the entire cohort of 1132 patients (stroke or death, OR = 1.0, 95% CI: 0.3-3.1 and restenosis, HR = 1.1, 95% CI: 0.6-2.0). In addition, outcome in the 4 studies with both treatments were analyzed separately to differentiate treatment effect and study effects.…”

“…From the 84 eligible articles (7609 patients, possibly including duplicate patients and interventions others than CEA/CAS), we received IPD from 13 studies. 15,16,18,19,[24][25][26][27][28][29][30][31][32] From the remaining 71 studies, IPD could not be retrieved because 30 authors did not respond, 26 did respond but the data were not available [no access to the data anymore without a clear reason why (13); no access to the data anymore because of change of institution, retirement, or institutional/study group restrictions (7); data destroyed or lost (4); data not digital (2)]. Three studies replied, but only provided summary data, and 11 study groups responded that they were not willing to participate (unknown reasons).…”

“…Data on restenosis during follow-up was available for 712 (400 CAS, 312 CEA) patients from 10 studies, 14,16,18,19,24,26,[28][29][30][31] with a median follow-up time of 13 months (interquartile range: 8.7-26). In the CAS group, restenosis greater than 50% occurred in 34 patients (8.5%), and in 16 patients (4.0%) when using 70% as cutoff.…”

“…Another concern with IPD is that certain studies may have a greater impact on outcome than others. However, we addressed this issue by conducting a sensitivity analysis by excluding the largest study, 16 and results did not change. Finally, we could not completely adjust for confounding due to clustering of patients within studies so residual confounding may still be present.…”

“…Although the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial is the only randomized controlled trial comparing CAS versus CEA that included a subgroup of patients with restenosis after prior ipsilateral CEA, no subgroup analysis was performed in these patients. 11 Numerous single centers and several larger registries have reported on outcome of patients treated for restenosis after prior ipsilateral CEA through CAS or CEA, [14][15][16] but only few (nonrandomized) studies reported on outcome of both treatment modalities. [16][17][18][19][20][21][22] Generally, small number of patients in each registry limits the current evidence on the most desirable treatment strategy for restenosis.…”