The management of carotid restenosis: a comprehensive review

Abstract

Carotid artery stenosis (CS) is a major medical problem affecting approximately 10% of the general population 80 years or older and causes stroke in approximately 10% of all ischemic events. In patients with symptomatic, moderate-to-severe CS, carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), has been used to lower the risk of stroke. In primary CS, CEA was found to be superior to best medical therapy (BMT) according to 3 large randomized controlled trials (RCT). Following CEA and CAS, restenosis remains an unsolved problem involving a large number of patients as the current treatment recommendations are not as clear as those for primary stenosis. Several studies have evaluated the risk of restenosis, reporting an incidence ranging from 5% to 22% after CEA and an in-stent restenosis (ISR) rate ranging from 2.7% to 33%. Treatment and optimal management of this disease process, however, is a matter of ongoing debate, and, given the dearth of level 1evidence for the management of these conditions, the relevant guidelines lack clarity. Moreover, the incidence rates of stroke and complications in patients with carotid stenosis are derived from studies that did not use contemporary techniques and materials.Rapidly changing guidelines, updated techniques, and materials, and modern medical treatments make actual incidence rates barely comparable to previous ones. For these reasons, RCTs are critical for determining whether these patients should be treated with more aggressive treatments additional to BMT and identifying those patients indicated for surgical or endovascular treatments. This review summarizes the current evidence and controversies concerning the risks, causes, current treatment options, and prognoses in patients with restenosis after CEA or CAS.

Estimated Glomerular Filtration Rate as a Predictor of Restenosis After Carotid Stenting Using First-Generation Stents

“…The treatment recommendations for carotid ISR are not as clear as those for primary stenosis, and determining the optimal ISR treatment modalities remains an unsolved problem that affects a large number of patients. 48 Although endovascular approaches to ISR vary according to the clinical and lesion characteristics of the affected patients, the most commonly used methods are angioplasty alone, cutting balloon angioplasty, drug-eluting balloon angioplasty, and bare metal and drug-eluting stent implantations. [49][50][51] Our algorithm utilized a conservative approach, with the use of more aggressive treatments in addition to the best medical therapies for those patients who did not show symptoms and who were diagnosed with 50% to 69% ISR.…”

Carotid duplex ultrasound: interpretations and clinical applications

“…There are several reports of the restenosis incidence ranging from 5% to 22% and from 2.7% to 33% after CEA and CAS, respectively. 15 After carotid revascularization, the blood flow velocity is observed to be greater than normal using carotid ultrasound, and so caution is needed when interpreting the observations. 14 Appropriate criteria for interpreting carotid duplex sonography findings after carotid revascularization have not yet been established, and so it is necessary to establish and regularly verify laboratory standards.…”

Periprocedural complications and risk factors after carotid stenting in patients with concomitant coronary artery disease

“…Около 87% от инсултите са исхемични, като 30% от тях са причинени от атеросклеротична плака в каротидната артерия, предизвикваща стеноза и/или тромбоза в нея. Тромбоемболизъм от 50-99% стеноза на вътрешната каротидна артерия е причина за приблизително 10-15% от инсултите при възрастни [1][2][3]. Каротидна стеноза над 50% се среща в твърде широк диапазон сред общата популация, като с напредването на възрастта отчетливо прогресира: при пациенти над и под 70 г. тя е съответно 12,5% и 4,8% при мъже, а при жени е 6,9% и 2,2 % [4,5].…”

“…Неусложненото каротидното стентиране при използване на стент със затворена клетка е при 97,7% от пациентите, при стентиране с отворена клетка със свободна зона 5,89mm 2 е 88,0%, а с отворена клетка -свободна зона 10,71mm 2 е 80,0%. Обратно, най-голяма честота на перипроцедурни усложнения ТИА (13,3%) и исхемичен инсулт (6,7%) е регистрирана в групата болни, при които е имплантиран стент с отворена клетка с най-голяма свободна зона -10,71mm 2 . Статистическа достоверно, честотата на ТИА и инсулт е по-висока в групата пациенти с имплантиран стент с отворена клетка и по-ниска при пациентите с имплантиран каротиден стент със затворена клетка -p = 0,001.…”