Long-term Comparative Outcomes of Carotid Artery Stenting Following Previous Carotid Endarterectomy vs De Novo Lesions

Abstract

Purpose: To report the long-term outcomes of patients who underwent carotid artery stenting (CAS) for de novo carotid stenosis vs patients treated for restenosis after carotid endarterectomy (CEA). Methods: A retrospective review was conducted of all 385 patients (mean age 68.6±9.6 years; 231 men) who underwent 435 CAS procedures at a large tertiary care center between January 1999 and December 2013. For analysis, patients were stratified based on their lesion type [de novo (dn) vs post-CEA restenosis (res)] and subclassified by symptoms status [symptomatic (Sx) or asymptomatic (Asx)], creating 4 groups: (1) CAS-dn Asx, (2) CAS-dn Sx, (3) CAS-res Asx, and (4) CAS-res Sx. For the CAS-res group, the mean elapsed time from CEA to CAS was 72.4±63.6 months. Outcomes included target vessel reintervention (TVR) and in-stent restenosis (ISR), the latter defined by a carotid duplex ultrasound velocity >275 cm/s. Results: The main indication for initial carotid angiography with possible revascularization was severe carotid stenosis (≥70%-99% on duplex) in both CAS-dn and CAS-res groups (83.6% vs 83.7%, p=0.999). There were no significant differences in the percentage of patients with postintervention residual stenosis (<30%; 100% each arm) or complications between CAS-res vs CAS-dn: in-hospital stroke (1.4% vs 1.8%, respectively), myocardial infarction (0.9% vs 0%), or death (0.9% vs 0%). Mean follow-up was 62.4±45.6 months (median 53.5, range 1–180). Average clinical/TVR follow-up was greater for the CAS-res group (71.9±48.6 months) compared with 53.3±40.5 months for the CAS-dn group (p<0.001). Across the 4 study groups, there were no differences in freedom from ISR (p=0.174) or TVR (p=0.856). Multivariate analysis found peripheral vascular disease (PVD) as the sole ISR independent predictor [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.03 to 3.62, p=0.041], while significant predictors for TVR were age <65 years at the time of the procedure (HR 2.55, 95% CI 1.05 to 6.18, p=0.039) and PVD (HR 2.46, 95% CI 1.03 to 5.87, p=0.043). Conclusion: The current study suggests that CAS is a feasible and durable therapeutic option for recurrent restenosis after CEA. Long-term outcomes were similar for patients treated for de novo lesions or post-CEA restenosis. Age and PVD appear to influence long-term CAS durability.

Anatomical and Technical Factors Influence the Rate of In-Stent Restenosis following Carotid Artery Stenting for the Treatment of Post-Carotid Endarterectomy Stenosis

“…Among the clinical variables that were analyzed in this study, only younger age (< 70 years) was found to be statistically significant in the multivariate analysis. Mousa et al found that age < 65 years old was a significant predictor of restenosis [ 37 ]. With regard for peripheral arterial disease, young patients, who likely have a more aggressive form of systemic atherosclerotic disease, appear to be predisposed to requiring multiple procedures or reinterventions [ 38 ].…”

Perioperative outcomes after reoperative carotid endarterectomy are worse than expected

“…25,26 Similarly, there is no statistically significant difference in outcomes after CAS for treatment of de novo stenosis compared with CAS for restenosis after CEA. 27 As stents are being increasingly used for redo cases, expertise and experience in reoperative CEA may be decreasing, which may be partially responsible for the results observed in this study. 10,11 Improvements in surgical technique, patient monitoring, and perioperative therapy have progressively improved patient outcomes after primary CEA during the past two decades.…”

The myth of restenosis after carotid angioplasty and stenting

“…Many studies of restenosis included patients undergoing angioplasty alone and do not appear to reflect current ISR rates. A recent study found peripheral vascular disease to be an independent predictor of ISR 15. A long-term follow-up study by Baldi et al 16 evaluated patients treated with CAS up to 7 years after treatment and found ISR in 7.4%.…”