The evolving surgical management of recurrent carotid stenosis

Abstract

The traditional approach to recurrent carotid stenosis has been repeat endarterectomy or patch angioplasty. Concern with the durability of repeat carotid endarterectomy has resulted in our use of carotid resection with autogenous graft interposition. This study was designed to determine the outcome and efficacy of carotid resection compared with repeat carotid endarterectomy in the management of recurrent carotid stenosis. From 1974 to 1991, 162 operations (repeat carotid endarterectomy 105, carotid resection 57) were performed for recurrent carotid stenosis. Indication for operation was hemispheric symptoms in 63% of patients, nonlateralizing symptoms in 25%, asymptomatic stenosis in 7%, and previous stroke in 5%. Ninety-one percent of patients had stenosis greater than 90% on arteriography. The perioperative stroke rate for carotid resection was 3.5%, with a subsequent rate of 0.0064 strokes per year. For repeat carotid endarterectomy, the perioperative stroke rate was 1.9% with a subsequent rate of 0.011 strokes per year. Graft patency after carotid resection was 93% (mean follow-up, 35 months). Four patients treated with carotid resection had graft thrombosis, and two of the four remained asymptomatic. After repeat carotid endarterectomy, one patient had carotid thrombosis, and recurrent stenosis greater than 50% developed in 23 patients (mean follow-up, 64 months). Twenty patients treated with repeat carotid endarterectomy underwent an additional operation for further symptomatic recurrent carotid stenosis. We conclude carotid resection is a safe and effective alternative to repeat carotid endarterectomy for patients undergoing operation for recurrent carotid stenosis.

Durability of surgery for restenosis after carotid endarterectomy

“…There are only six reports of Ͼ100 procedures, 6,13,16,30,33,36 10 reports of 50 to 99 procedures, 7,14,15,17,19,23,24,27,34,35 and 14 reports of Ͻ49 procedures. 5,18,[20][21][22]25,26,28,29,31,32,37,38 The reported 30-day stroke and death rates range from 0% to 5.4% (Table I).…”

“…Carotid resection with the placement of an interposition graft is another surgical option. 19,30 In our opinion, interposition grafting is a distinct procedure; therefore, it was an exclusion criterion. In the present series, however, two patients with secondary recurrent stenosis received an interposition graft for tertiary revascularization.…”

Primary carotid artery stenting versus carotid artery stenting for postcarotid endarterectomy stenosis

“…Redo is believed to be more difficult than primary CEA because of the dense scarring surrounding the carotid artery and the difficulty in obtaining tissue cleavage planes. Morbidity (including cranial nerve injury) and mortality rates of 8% to 20% after redo CEA have been reported [22][23][24] ; however, several other authorities have reported better results. [25][26][27][28][29][30] Carotid percutaneous transluminal angioplasty and stenting is increasing in popularity and has been advocated by some investigators as an alternative to reoperation for post-CEA carotid stenosis.…”

Carotid artery stenting outcomes are equivalent to carotid endarterectomy outcomes for patients with post-carotid endarterectomy stenosis

“…[7][8][9] This is largely due to the inherent risks in any open reintervention in a previously operated field, such as increased scar tissue, which can obscure tissue planes and make identification of anatomic structures and surgical landmarks more challenging. Reoperation can have morbidity and mortality rates as high as 8% to 20%, [13][14][15][16][17][18][19][20] although recent literature suggests that this is improving. 6,[21][22][23] O'Donnell et al reported on the results from a metaanalysis of six series that showed a 4.2% stroke rate and a 1% mortality rate for redo carotid surgery, and indicated that the incidence of cranial nerve injury in these patients averaged 8.5%.…”