Carotid angioplasty and stenting versus redo endarterectomy for recurrent stenosis

The management of carotid restenosis: a comprehensive review

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.

Carotid artery stenting: Current state of evidence and future directions

Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.

Perioperative outcomes after reoperative carotid endarterectomy are worse than expected

OBJECTIVE

Reoperative carotid endarterectomy (CEA) can be technically challenging because of significant scarring as a consequence of the initial CEA procedure. There are limited data that describe outcomes after reoperative CEA, and as such, our goal was to determine the effect of reoperative CEA on perioperative outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients undergoing index and reoperative CEA between 2005 and 2014. Multivariate analysis was performed to assess the effect of reoperative CEA on outcomes including stroke, major adverse cardiovascular event, and procedure time.

RESULTS

There were 75,943 index and 140 reoperative CEAs identified. No differences were found in baseline demographics or comorbidities except that the reoperative group had a higher incidence of patients with end-stage renal disease (3.6% vs 1.1%; P = .004). Prior stroke with deficit (20.8% vs 15.4%; P = .137) and without deficit (11.5% vs 9.1%; P = .43) were similar between reoperative and index CEA groups. Both the reoperative and index initial CEA cohorts had comparable rates of surgical site infection (0.7% vs 0.3%; P = .462), return to the operating room (3.6% vs 4%; P = .816), readmission with 30 days (2.1% vs 6.9%; P = .810), myocardial infarction (2.1% vs 0.9%; P = .125), and perioperative death (0.7% vs 0.9%; P = .853). The reoperative cohort had a significantly higher rate of perioperative stroke (5.0% vs 1.6%; P = .002) and a longer operative duration (137 ± 54 vs 116 ± 49 minutes; P < .001). Multivariate analysis revealed that reoperative CEA was an independent factor for postoperative stroke (odds ratio, 3.71; 95% confidence interval [CI], 1.61-8.57; P = .002), major adverse cardiovascular event (odds ratio, 2.76; 95% CI, 1.32-5.78; P = .007), and longer procedure time (means ratio, 1.21; 95% CI, 1.12-1.30; P < .001).

CONCLUSIONS

Reoperative carotid surgery is associated with a longer operative time and higher risk for perioperative stroke compared with index CEA. This information informs the risk-benefit analysis for reoperation.

Repeated carotid endarterectomy versus carotid artery stenting for patients with carotid restenosis after carotid endarterectomy: Systematic review and meta-analysis

PURPOSE

Carotid restenosis (CRS) after carotid endarterectomy (CEA) is an issue that cannot be ignored. This study was undertaken to compare the outcomes of repeated CEA (redo CEA) and carotid artery stenting (CAS) for CRS after CEA.

METHODS

We performed a systematic analysis using the search terms "CEA restenosis," "carotid restenosis," or "CEA recurrent stenosis" in the MEDLINE, EMBASE, PubMed, and Cochrane Library databases. After applying the inclusion criteria, all available data were summarized to evaluate the effects of redo CEA and CAS for patients with CRS after prior CEA.

RESULTS

Fifty articles (9 comparative studies and 41 noncomparative studies) involving 4,399 patients were included. No differences were observed in the 30-day perioperative mortality, stroke and transient ischemic attack rates in the comparative studies (P > .05) and the noncomparative studies (P > .05). Patients undergoing redo CEA suffered more cranial nerve injuries (CNIs) than those undergoing CAS (P < .05), but most of these cases recovered within 3 months. Patients treated with redo CEA exhibited similar myocardial infarction (MI) rates to those treated with CAS in the comparative studies (P = .53), but the rate was higher in the noncomparative studies (P < .01). However, a nonsignificant difference was noted in freedom from stroke at 36 months in the comparative studies (P = .47) and at 12 months in the noncomparative studies (P = .89). The risk of restenosis was greater in the CAS patients than in the redo CEA patients (P < .05 for comparative and noncomparative studies).

CONCLUSION

Both redo CEA and CAS are safe and feasible for CRS after CEA. Although the incidences of CNI and MI were increased in the redo CEA group, most of the CNI cases were reversible. Patients treated with CAS were more likely to develop restenosis than those treated with redo CEA over long-term follow-up.

Indications for treatment of recurrent carotid stenosis

Background

There is significant variation in the indications for intervention in patients with recurrent carotid artery stenosis. The aim of the present study was to describe these indications in a contemporary cohort of patients.

Methods

This was a systematic review of all peer-reviewed studies reporting on the indications for carotid intervention in patients with recurrent stenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS) that were published between 1990 and 2012.

Results

There were 50 studies reporting on a total of 3524 patients undergoing a carotid procedure; of these, 3478 underwent CEA as the initial intervention. Reintervention was by CEA in 2403 patients and by CAS in 1121. Only 54·7 per cent of the patients were treated for any symptoms and, importantly, just 444 (23·1 per cent of 1926 symptomatic patients) underwent intervention for documented ipsilateral symptoms. None of the studies reported whether the patients were evaluated for other sources of emboli. The remaining 45·3 per cent of patients had asymptomatic restenosis and in the majority of the studies were treated when the degree of stenosis exceeded 80 per cent. The time to repeat intervention was significantly longer in patients with recurrent atherosclerosis, in asymptomatic patients and in patients undergoing CEA.

Conclusion

The reported criteria for retreatment of carotid stenosis were not rigorous and there is still significant ambiguity surrounding the indications for intervention.

Carotid Angioplasty and Stenting is Safe in Women

Background

Results of randomized controlled trials have shown that carotid endarterectomy poses greater perioperative risks to women than to men. There are limited studies regarding sex differences in carotid angioplasty and stenting.

Objectives

To compare male and female patients undergoing carotid stenting with regard to their intraprocedural complications and 30-day outcome.

Methods

We reviewed patients who underwent carotid stenting between 1997 and 2007 at our tertiary centre. Distal protection devices were used in all patients after 1999. Demographics, risk factors, intraprocedural complications, and 30-day outcomes were compared between female and male patients.

Results

Among 243 patients who underwent 255 procedures, 67 were women (27.6%). The mean (SD) age of the female patients was 72.2 ± 8.4 years and that of the male patients was 72.0 ± 9.6 years ( P = .83). The majority of patients had symptomatic carotid artery disease; 11 women (16.4%) and 30 men (16.0%) were asymptomatic. The following intraprocedural complications were noticed in female vs male patients: asymptomatic carotid and/or iliac dissections 7.5% vs 0% ( P = .001), minor stroke 0% vs 1.1% ( P = 1.00), major stroke 0% vs 0.5% ( P = 1.00), and cardiac dysrhythmias 3% vs 2.7% ( P = 1.00). At 30 days, the outcomes in women vs men were as follows: mortality 3.0% vs 3.2% ( P = 1.00), major stroke 3.0% vs 2.1 % ( P = .66), and minor stroke 3.0% vs 3.2% ( P = 1.00).

Conclusion

Although minor asymptomatic intraprocedural dissections were more common in women, we did not find any impact of sex on the 30-day outcome. We concluded that carotid stenting can be performed as safely in women as in men.

Article Commentary: Late Outcomes of Carotid Artery Stenting: A Critical Review

The role of carotid artery stenting (CAS) as an alternative to carotid endarterectomy for the treatment of extracranial carotid occlusive disease for stroke prevention continues to evolve. Although technical and device refinements aimed at making CAS safer continue to this day, safety as measured by 30-day and 1-year outcomes has been the primary recipient of regulatory and practice attention. Relatively less emphasis has been placed on the incidence of recurrent stenosis after CAS and the efficacy of CAS in late stroke prevention. Data on late outcomes of CAS, including factors of potential influence, have been emerging and are addressed in this review.

Multicentric retrospective study of endovascular treatment for restenosis after open carotid surgery

OBJECTIVES

To analyse perioperative and midterm outcomes of carotid artery stenting (CAS) for symptomatic >50% and asymptomatic >70% restenosis after open carotid surgery (OCS).

DESIGN

A multicentric retrospective study.

METHODS

Outcome measures 30-day death, neurologic and anatomic (thrombosis, restenosis) events. Univariant and multivariant logistic regression analyses were performed to identify predictive factors for neurologic and anatomic events.

RESULTS

A total of 249 patients with a mean age of 69 years (range, 45-88) were treated for asymptomatic (86%) or symptomatic (14%) restenosis. The 30-day combined operative mortality and stroke morbidity was 2.8% in asymptomatic patients and 2.9% in symptomatic patients. Events during follow-up (mean duration, 29 months) included stroke in four cases, TIA in two, stent thrombosis in four and restenosis in 21. Kaplan-Meier estimates of overall survival, neurologic-event-free survival, anatomic-event-free survival and reintervention-free survival were 95.4%, 94.7%, 96.7% and 99.5%, respectively, at 1 year and 80.3%, 93.8%, 85.1% and 96%, respectively, at 4 years. Multivariant analysis showed that statin use was correlated with a lower risk of anatomic events (odds ratio (OR) = 0.15 (95% confidence interval (CI) 0.03-0.68), p = 0.01) and that bypass was associated with a higher risk of anatomic events than endarterectomy (OR = 5.0 (95% CI 1.6-16.6), p = 0.009).

CONCLUSION

CAS is a feasible therapeutic alternative to OCS for carotid restenosis with acceptable risks in the perioperative period. Restenosis rate may be higher in patients treated after bypass.

Tratamento endovascular da reestenose carotídea: resultados em curto prazo

CONTEXTO: O tratamento cirúrgico da reestenose carotídea apresenta alta taxa de lesão neurológica. Contrariamente, o tratamento endovascular da doença obstrutiva carotídea extracraniana tem se tornado mais factível e gradualmente menores taxas de risco cirúrgico vêm sendo reportadas, tornando-se uma opção em situações especiais, e provavelmente poderá ser considerado o tratamento padrão para reestenose carotídea. OBJETIVOS: Avaliar a aplicabilidade, a segurança e a eficácia da angioplastia com o uso do stent (ACS) no tratamento da reestenose carotídea (REC) no intraoperatório e no pós-operatório recente (<30 dias). MÉTODOS: Análise retrospectiva dos pacientes portadores de reestenose carotídea submetidos à angioplastia com stent no período de março 2000 a junho de 2004. RESULTADOS: Foram analisados 19 pacientes com reestenose carotídea. Quatorze pacientes (74%) eram do sexo masculino, com média de idade de 74 anos. Quinze (79%) eram assintomáticos com estenose >80%, enquanto quatro (21%) eram sintomáticos com estenose >70%. Apenas em um paciente não foi utilizado sistema de proteção cerebral. O sucesso técnico foi obtido em todos os casos. Não houve morte ou acidente vascular encefálico no intra ou no pós-operatório recente (30 dias). CONCLUSÃO: O tratamento endovascular da reestenose carotídea mostrou-se uma abordagem factível e segura em curto prazo

Duplex criteria for determining ≥50% and ≥80% internal carotid artery stenosis following carotid endarterectomy with patch angioplasty

The purpose of this study was to determine optimal velocities for detecting ≥50% and ≥80% restenosis prior to considering carotid intervention/carotid artery stenting (CAS) after carotid endarterectomy (CEA) with patching in symptomatic and asymptomatic patients. Two hundred CEA patients with 195 pairs of imaging (duplex ultrasound versus computed tomography angiography [CTA]/carotid arteriography) were analyzed. Peak systolic velocities (PSVs), end diastolic velocity (EDV) and internal carotid artery/common carotid artery (ICA/CCA) ratios were correlated to angiography. Receiver operator characteristic (ROC) curves determined optimal velocity criteria in detecting ≥50% and ≥80% restenosis. The mean PSVs for ≥50% and ≥80% restenosis were 248 and 404 c/s, respectively ( P < 0.001). A PSV of ≥213 c/s was optimal for ≥50% restenosis with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy (OA) of 99%, 100%, 100%, 98% and 99%, respectively. An ICA PSV of 274 c/s was optimal for ≥80% restenosis with sensitivity, specificity, PPV, NPV and OA of 100%, 91%, 99%, 100% and 99%, respectively. ROC analysis showed that PSVs were significantly better than EDVs and ICA/CCA ratios in detecting ≥50% restenosis. Standard duplex velocity criteria should be revised after CEA using patching. Specific carotid duplex velocities can be used to detect ≥50% and ≥80% restenosis after CEA with patch closure prior to carotid intervention/CAS.

Open surgery remains a valid option for the treatment of recurrent carotid stenosis

OBJECTIVE

The choice between open surgery (OS) and transluminal carotid angioplasty with stenting (CAS) for the treatment of primary carotid stenosis remains controversial. However, CAS is considered a valid option for selected cases, such as recurrent carotid stenosis (RCS). Tertiary RCS seems to be a concerning issue after CAS but few large reports focused on the durability of CAS and OS. We report our early and long-term results with OS for RCS.

METHODS

From 1989 to 2006, perioperative data regarding 4245 consecutive surgical carotid reconstructions was prospectively collected. Patients whose indication was RCS were subjected to further analysis. Indications for surgery were symptomatic RCS >50% or asymptomatic RCS >80%. Freedom from neurologic event was defined as the absence of any ipsilateral symptom at any time after the procedure. Kaplan-Meier analysis was used to estimate freedom from reintervention, freedom from restenosis >50% and occlusion, freedom from neurologic event and survival.

RESULTS

A total of 119 patients (2.8%) with RCS underwent OS. The average time from the primary OS was 59.4 +/- 54.5 months (range, 2-204). Forty-nine patients (41%) were symptomatic. In 103 patients (87%), the technique did not differ from a primary approach. Postoperative (<30 days) combined stroke and death rate was 3.3%. Cranial nerve injury occurred in 5 cases (4.2%). With a mean follow-up of 53 +/- 48 months (range, 1-204), 3 patients had an ipsilateral stroke (including one hemorrhagic stroke) and 7 were diagnosed with a tertiary RCS >50%. At 5 years, Kaplan-Meier estimates of freedom from reintervention, freedom from restenosis and occlusion, freedom from neurologic event, and survival were 99%, 91%, 89%, and 91%, respectively.

CONCLUSION

OS for RCS is not a high-risk procedure and provides excellent long-term results, with low rates of tertiary RCS and reinterventions. The comparison between OS and CAS in this indication suffers from the absence of standardized follow-up paradigms after primary OS and the lack of prospective randomized trial comparing the two techniques. Despite these limitations in the available data, we conclude that OS should remain the first line therapy when treatment of RCS is indicated.

Endarterectomy or carotid artery stenting: the quest continues

BACKGROUND

Carotid endarterectomy (CEA) is still considered the "gold-standard" of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endovascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis. This review presents the development of CAS according to early reports, results of recent randomized trials, and future perspectives regarding CAS.

METHODS

A literature search using the PubMed and Cochrane databases identified articles focusing on the key issues of CEA and CAS.

RESULTS

Early nonrandomized reports of CAS showed variable results, and the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy trial led to United States Food and Drug Administration approval of CAS for the treatment of patients with symptomatic carotid stenosis. In contrast, recent trials, such as the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial and the Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis trial, (re)fuelled the debate between CAS and CEA. In the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial, the complication rate of ipsilateral stroke or death at 30 days was 6.8% for CAS versus 6.3% for CEA and showed that CAS failed the noninferiority test. Analysis of the Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis trial showed a significant higher risk for death or any stroke at 30 days for endovascular treatment (9.6%) compared with CEA (3.9%). Other aspects-such as evolving best medical treatment, timely intervention, interventionalists' experience, and analysis of plaque composition-may have important influences on the future treatment of patients with carotid artery stenosis.

CONCLUSIONS

CAS performed with or without embolic-protection devices can be an effective treatment for patients with carotid artery stenosis. However, presently there is no evidence that CAS provides better results in the prevention of stroke compared with CEA.