Redo carotid endarterectomy versus primary carotid endarterectomy

Role of carotid duplex in the assessment of carotid artery restenosis after endarterectomy or stenting

Introduction

Redo carotid endarterectomy (CEA) and carotid stenting (CAS) are often performed when there is evidence of post-procedural restenosis. The incidence of restenosis after carotid reconstruction is not negligible, ranging from 5 to 33%. The diagnosis of significant internal carotid artery (ICA) restenosis is usually based on duplex ultrasound (US) criteria, mostly on peak-systolic flow velocity (PSV). However, there have been no generally accepted duplex US criteria for carotid restenosis after CAS or CEA.

Methods

In this systematic review, the PubMed/ Medline and Scopus databases were screened to find trials that reported duplex US criteria for significant restenosis after CEA and/or CAS. Only those reports were analyzed in which the restenoses were also assessed by CT/MR or digital subtraction angiography as comparators for duplex US.

Results

Fourteen studies met the predetermined search criteria and were included in this review. In most studies, PSV thresholds for significant in-stent ICA restenosis after CAS were higher than those for significant stenosis in non-procedurally treated (native) ICA. Many fewer studies investigated the US criteria for ICA restenosis after CEA. Despite the heterogeneous data, there is a consensus to use higher flow velocity thresholds for assessment of stenosis in stented ICA than in native ICA; however, there have been insufficient data about the flow velocity criteria for significant restenosis after CEA. Although the flow velocity thresholds for restenosis after CAS and CEA seem to be different, the large studies used the same duplex criteria to define restenosis after the two procedures. Moreover, different studies used different flow velocity thresholds to define ICA restenosis, leading to variable restenosis rates.

Discussion

We conclude that (1) further examinations are warranted to determine appropriate duplex US criteria for restenosis after CAS and CEA, (2) single duplex US parameter cannot be used to reliably determine the degree of ICA restenosis, (3) inappropriate US criteria used in large studies may have led to false restenosis rates, and (4) studies are required to determine if there is a benefit from redo carotid artery procedure, such as redo-CEA or redo-CAS, starting with prospective risk stratification studies using current best practice non-invasive care alone.

Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy

BACKGROUND AND PURPOSE

Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke. The optimal procedural modality for this indication has yet to be determined. Here, we evaluate the in-hospital outcomes of transcarotid artery revascularization (TCAR), redo-CEA, and transfemoral carotid artery stenting (TFCAS) in a large contemporary cohort of patients who underwent treatment for restenosis after CEA.

METHODS

We performed a retrospective analysis of all patients in the vascular quality initiative database who underwent TCAR, redo-CEA, or TFCAS after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral CAS were excluded from this analysis. In-hospital outcomes following TCAR versus CEA and TCAR versus TFCAS were evaluated using multivariate logistic regression analysis.

RESULTS

A total of 4425 patients were available for this analysis. There were 963 (21.8%) redo-CEA, 1786 (40.4%) TFCAS, and 1676 (37.9%) TCAR. TCAR was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% CI, 0.24-0.70], P=0.021), stroke (OR, 0.46 [95% CI, 0.23-0.93], P=0.03), myocardial infarction (MI; OR, 0.32 [95% CI, 0.14-0.73], P=0.007), stroke/transient ischemic attack (OR, 0.42 [95% CI, 0.24-0.74], P=0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24-0.70], P=0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the 2 groups (OR, 0.99 [95% CI, 0.28-3.5], P=0.995). TCAR was also associated with lower odds of stroke/transient ischemic attack (OR, 0.37 [95% CI, 0.18-0.74], P=0.005) when compared with TFCAS. There was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI between TCAR and TFCAS.

CONCLUSIONS

TCAR was associated with significantly lower odds of in-hospital stroke, MI, stroke/transient ischemic attack, stroke/death, and stroke/death/MI when compared with redo-CEA and lower odds of in-hospital stroke/transient ischemic attack when compared with TFCAS. Additional long-term studies are warranted to establish the role of TCAR for the treatment of restenosis after CEA.

Propensity-Matched Comparison for Carotid Artery Stenting in Primary Stenosis Versus after Carotid Endarterectomy Restenosis

BACKGROUND

Carotid artery stenting (CAS) has been proposed as the treatment of choice in case of restenosis (RES) after carotid endarterectomy (CEA). The aim of this study was to analyze periprocedural results of CAS for the treatment of post-CEA RES compared with those of CAS performed for primary carotid stenosis (PRS).

METHODS

Data from consecutive patients submitted to CAS at our institution from 2008 to 2016 were retrospectively reviewed. Patients with in-stent RES were excluded. Initially, preoperative risk factors, demographics, intraoperative variables, and perioperative outcomes were analyzed according to the indication groups (PRS and RES). Then, propensity score matching was performed obtaining 2 homogeneous groups of patients. Covariates included were age, gender, hypertension, hyperlipidemia, cardiac disease, chronic renal disease, symptomatic carotid plaque, and positive ipsilateral brain computed tomography scan. Intraoperative data and perioperative outcomes were then compared between the 2 matched groups.

RESULTS

Of 480 included patients, 300 (62.5%) underwent CAS for PRS, and 180 (37.5%) for RES. After propensity score analysis (158 patients/group), no significant difference was observed in terms of technical success, number, and type of stent used, except for need of intraoperative atropine administration that was higher in the PRS group (38.6% vs. 13.3%, respectively; P < 0.001). In the perioperative period, composite neurologic event was significantly higher in the PRS group (7.6% vs. 1.9%; P = 0.017). Moreover, need of ionotropic support was higher in the PRS group (8.9% vs. 1.9%; P = 0.0069). Myocardial infarction rate and 30-day mortality were similar in both groups (P = 0.317; P = 1, respectively).

CONCLUSIONS

In a large single-center experience, CAS for post-CEA RES was associated with a significantly lower risk of any neurologic event and hemodynamic instability in the perioperative period compared with CAS performed for primary carotid lesions. Our results confirm that post-CEA RES may represent an elective indication for CAS.

Endovascular Repair of Carotid Artery Pseudoaneurysm using Transcarotid Artery Revascularization Flow Reversal Technique

Carotid artery aneurysm overall is a rare occurrence with <1% formed after carotid endarterectomy (CEA). Several methods of repair have been described including open and endovascular techniques. Transcarotid artery revascularization (TCAR) with stenting using the reverse flow technique has been used in patients with carotid artery stenosis with neck irradiation, previous neck surgeries, or for those who are at high risk for open surgery. We describe a patient with a post-CEA pseudoaneurysm of the extracranial internal carotid artery that was repaired using the TCAR flow reversal approach with coiling of the external carotid artery.

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.

Restenosis After Carotid Endarterectomy: Insight Into Risk Factors and Modification of Postoperative Management

BACKGROUND

Restenosis after carotid endarterectomy (CEA) is a potential complication after surgery for carotid stenosis. Stroke after CEA is a debilitating complication secondary to restenosis, and modification of postoperative care may be necessary to decrease the incidence of postoperative stroke after CEA. We sought to identify the clinical and patient factors that are associated with this complication.

METHODS

A retrospective analysis of all neurosurgical patients who underwent CEA for symptomatic or asymptomatic carotid stenosis was performed. Factors were compared against the outcome variable in a univariate analysis. A multivariate logistic regression model was used to identify independent predictive variables. We used Kaplan-Meier analysis to compare the effect of the variables on long-term event-free survival.

RESULTS

A total of 273 CEA procedures and their outcomes were analyzed with a mean follow-up of 50.7 months. Twenty-one patients had restenosis (7.6%). Rates of restenosis and restenosis-free survival were analyzed with Kaplan-Meier curves (log-rank test). In the multivariate model, a family history of stroke was the only variable that was significantly associated with restenosis after CEA.

CONCLUSIONS

Our findings suggest that a family history of stroke is an important factor that predisposes patients to restenosis after CEA. Restenosis-free survival is influenced by the presence of hyperlipidemia, age, and family history of stroke. Closer surveillance with more frequent follow-up and multidisciplinary management may be beneficial in patients who have these risk factors to prevent restenosis and prolong restenosis-free survival.

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.

Primary Stenting for Recurrent Stenosis Following Carotid Endarterectomy

Background:

Carotid angioplasty and stenting is an accepted alternative treatment for severe restenosis following carotid endarterectomy. Balloons may not be required to effectively treat these lesions, given their altered histopathology compared to primary atherosclerotic plaque and tendency to be less calcified. Primary stenting using self-expanding stents alone may, therefore, be a safe and effective treatment for restenosis post-carotid endarterectomy.

Methods:

We review our experience in the treatment of 12 patients with symptomatic severe restenosis following carotid endarterectomy with primary stent placement alone.

Results:

Self-expanding stent placement alone reduced the mean internal carotid artery stenosis from 85% to 29%. Average peak systolic velocity determined at the time of ultrasonography decreased from 480 cm/s at initial presentation to 154 cm/s post-stent deployment and further decreased to 104 cm/s at one year follow-up. The stented arteries remained widely patent with no evidence of restenosis. A single peri-procedural ipsilateral transient ischemic event occurred. There were no cerebral or cardiac ischemic events recorded at one year of follow-up.

Conclusions:

In this series, primary stent placement without use of angioplasty balloons was a safe and effective treatment for symptomatic restenosis following carotid endarterectomy.

Carotid Endarterectomy: A Review

Background:

Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEAresults.

Investigation:

Brain imaging with CTor MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRAor CTangiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment.

Indications:

Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50 - 69% symptomatic stenosis, and those with asymptomatic stenosis ≥ 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions.

Techniques:

Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. “Eversion” endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis.

Carotid angioplasty and stenting:

Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA.

Auditing:

It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.

The indications of carotid artery stenting in symptomatic patients may need to be reconsidered

According to the 2011 and the 2014 updated American Heart Association/American Stroke Association Guidelines, carotid artery stenting (CAS) is indicated as an alternative to carotid endarterectomy (CEA) for the management of symptomatic carotid patients. According to these recommendations, CAS is preferred to CEA in symptomatic patients with specific technical, anatomic, or physiological characteristics that render these individuals at "high risk" for surgery (e.g., contralateral carotid occlusion, previous neck irradiation, recurrent carotid stenosis, and so forth). This article presents emerging data suggesting that most of these criteria do not comprise contraindications for CEA. In fact, CEA is associated with similar (or even better) outcomes compared with CAS in many such "high-risk" patients. Based on these results, the indications of CAS in symptomatic patients may need to be reconsidered.

Carotid artery stenting has increased risk of external carotid artery occlusion compared with carotid endarterectomy

OBJECTIVE

The external carotid artery (ECA) can be an important source of cerebral blood flow in cases of high-grade internal carotid artery stenosis or occlusion. However, the treatment of the ECA is fundamentally different between carotid endarterectomy (CEA) and carotid artery stenting (CAS). CEA is routinely associated with endarterectomy of the ECA, whereas CAS excludes the ECA from direct flow. We hypothesize that these differences make ECA occlusion more common after CAS. Further, the impact of CAS on blood flow into the ECA is interesting because the flow from the stent into the ECA is altered in a way that may promote local inflammation and may influence in-stent restenosis (ISR). Thus, our objective was to use our institutional database to identify whether CAS increased the rate of ECA occlusion and, if it did, whether ECA occlusion was associated with ISR.

METHODS

Patients undergoing CAS or CEA from February 2007 to February 2012 were identified from our institutional carotid therapy database. Preoperative and postoperative images of patients who followed up in our institution were included in the analysis of ECA occlusion and rates of ISR.

RESULTS

There were 210 (67%) CAS patients and 207 (60%) CEA patients included in this analysis. Despite CAS patients being younger (68 vs 70 years), having shorter follow-up (12.5 vs 56.2 months), and being more likely to take clopidogrel (97% vs 35%), they had an increased rate of ECA occlusion (3.8%) compared with CEA patients (0.4%). CAS patients who went on to ECA occlusion had an increased incidence of prior neck irradiation (50% vs 15%; P = .03), but we did not identify an association of ECA occlusion with ISR >50%.

CONCLUSIONS

Whereas prior publications have identified increased rates of external carotid stenosis, this is the first demonstration of increased ECA occlusion after CAS. However, ECA occlusion is uncommon (∼4%) and did not have an association with ISR >50%. Future work modeling ECA flow patterns before and after CAS will be used to further test this interaction.

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

BACKGROUND

Outcomes for patients undergoing intervention for restenosis after prior ipsilateral carotid endarterectomy (CEA) in the era of carotid angioplasty and stenting (CAS) are unclear. We compared perioperative results and durability of CAS vs CEA in patients with symptomatic or asymptomatic restenosis after prior CEA and investigated the risk of reintervention compared with 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. End points 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 = .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 = .5). Redo CEA vs primary CEA had increased stroke/death/MI rate in both symptomatic (6.6% vs 2.3%; P = .05) and asymptomatic patients 4.4% vs 1.7%; P = .03). Prior ipsilateral CEA was an independent predictor for stroke/death/MI among all patients undergoing CEA (odds ratio, 2.1; 95% confidence interval, 1.3-3.5). No difference in cranial nerve injury was identified between redo CEA and primary CEA (5.2% vs 4.7%; P = .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 reintervention was increased compared with patients undergoing primary CEA.

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.

Centers for Medicare and Medicaid Services conducts a medical evidence development and coverage advisory committee meeting on carotid atherosclerosis

Publication of the eagerly anticipated Carotid Revascularization Endarterectomy Versus Stenting Trial in May 2010 was anticipated to engender much activity in the realm of interventions for carotid stenosis. Specifically, a variety of professional societies, including the Society for Vascular Surgery (SVS), published updated practice guidelines in the calendar year 2011, timed to include data from large-scale well-conducted clinical trials comparing carotid endarterectomy with carotid artery stenting (CAS). In anticipation of a renewed application to the Centers for Medicare and Medicaid Services (CMS) to reconsider the national coverage determination for CAS, the SVS Board of Directors voted in June 2011 against any change in the national coverage determination for CAS. CMS convened a Medicare evidence development and coverage advisory committee (MEDCAC) meeting to consider fundamental aspects of the treatment of carotid atherosclerosis on January 25, 2012, to allow an unbiased and current deliberation of the state-of-the-art technology and science referable to the management of carotid atherosclerosis. The MEDCAC differs substantially from a reconsideration of coverage determination and, in this case, was built around seven research questions. The MEDCAC consists of a panel of experts who, after reviewing the literature and submitted comments by interested stakeholders, and after hearing testimony from invited speakers and at-large presentations, held a panel vote on the research questions. Given that management of carotid atherosclerosis is a core element of vascular surgical practice, the SVS had a major presence at the MEDCAC in the form of a comprehensive written document individually considering the research questions and a variety of presentations addressing various aspects in carotid disease management. The purpose of this report is to detail the SVS's position on the MEDCAC research questions referable to the management of carotid atherosclerosis and to otherwise detail the proceedings of the MEDCAC.

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.

Stroke prevention-surgical and interventional approaches to carotid stenosis

Extracranial carotidartery stenosis is an important cause of stroke that often needs treatment with carotid revascularization. To prevent stroke recurrence, carotid endarterectomy has been well-established for many years in treating symptomatic high- and moderate-grade stenosis. Carotid stenting is an appealing, less invasive alternative to carotid endarterectomy, and several recent trials have compared the efficacy of the 2 procedures in patients with carotid stenosis. Carotid artery stenting has emerged as an important mode of therapy for high-risk patients with symtomatic high-grade stenosis. This review focuses on the current data available that will enable the clinician to decide optimal treatment strategies for patients with carotid stenosis.

Carotid stenting for restenosis after endarterectomy

INTRODUCTION

Restenosis after carotid endarterectomy (CEA) has been described in 8-19% of patients, 14-23% of whom become symptomatic. This study analyzes our experience with carotid artery stenting (CAS) for post-CEA recurrent stenoses.

METHOD

Retrospective database and case-note review.

RESULTS

Between January 2000 and September 2008, a total of 27 patients (15 symptomatic) with hemodynamically significant internal carotid artery post-CEA restenosis underwent CAS. Median stenosis of target vessels was 90% (range 75-95%). There was one periprocedural death (3.7%); no others occurred during the median 34-month follow-up (range 0.1-84 months). There was one late transient ischemic attack 12 months after CAS that was not associated with in-stent restenosis. One 90% restenosis and one occlusion were detected during follow-up at 38 and 57 months after CAS. The remaining patients had no evidence of further restenosis and remained free from cerebrovascular symptoms.

CONCLUSION

CAS offers a feasible option for the management of carefully selected patients with symptomatic and asymptomatic restenosis after CEA.

Scar formation in the carotid sheath identified during carotid endarterectomy in patients with previous cardiac surgery: significance of history of intraoperative Swan-Ganz catheter insertion. Clinical article

OBJECT

Scar formation in the carotid sheath is often identified during carotid endarterectomy (CEA) in patients with previous cardiac surgery, and dissection of the carotid sheath and exposure of the carotid arteries in such patients are difficult. The purpose of the present study was to investigate factors related to scar formation identified during CEA in patients with previous cardiac surgery.

METHODS

Twenty-three patients with internal carotid artery stenosis (≥ 70%) and previous cardiac surgery underwent CEA. A patient was prospectively defined as having scar formation during CEA when scissors were required throughout dissection of the carotid sheath and exposure of the carotid arteries.

RESULTS

Scar formation was identified during dissection of the carotid sheath in 7 patients (30.4%). In all 7 patients, the side of CEA was identical to the side on which the Swan-Ganz catheter was inserted during cardiac surgery, and the incidence of previous ipsilateral Swan-Ganz catheter insertion was significantly higher in patients with the scar formation (100%) than in those without (31.3%). Seven (58.3%) of 12 patients with a history of ipsilateral Swan-Ganz catheter insertion had scar formation. Two of the 7 patients with scar formation experienced complications after CEA, including one patient with hemiparesis due to artery-to-artery embolism during surgery, and another patient with transient vocal cord paralysis.

CONCLUSIONS

A history of Swan-Ganz catheter insertion during previous cardiac surgery is associated with the presence of scar tissue in the ipsilateral carotid sheath and a higher risk of complications during CEA.

MMP and TIMP alterations in asymptomatic and symptomatic severe recurrent carotid artery stenosis

OBJECTIVES

This study aimed to determine whether the plasma levels of matrix metalloproteinases (MMPs)-2 and -9 and their specific inhibitors (tissue inhibitors of metalloproteinases (TIMPs-1 and -2)) were altered in patients with symptomatic and asymptomatic, severe, recurrent carotid artery stenosis.

PATIENTS

Fifty-two patients (out of a total of 621) who had undergone successful carotid artery endarterectomy (CEA) between 1999 and 2003 and developed recurrent carotid artery stenosis (>/=70%) were included in the study. Restenosis was symptomatic in 23 patients and asymptomatic in 29 patients.

METHODS

Recurrent carotid artery stenosis was classified based on presentation, and as early-intermediate (6 months to 3 years) or late (>3 years). A detailed clinical history was taken and two blood samples were drawn from each patient to determine plasma levels of MMPs and TIMPs along with other biological parameters. Recurrent stenosis was confirmed with computed tomographic angiography.

RESULTS

Patients with symptomatic restenosis had significantly (p<0.001) higher active MMP-2 and -9 plasma values and significantly (p<0.001) lower TIMP-1 and -2 plasma values when compared to patients with asymptomatic restenosis. Plasma concentrations of active MMPs were higher and TIMPs lower in patients affected with late recurrent stenosis as compared to early-intermediate restenosis (p<0.001). No differences were recorded in latent MMP plasma values. Multivariate analysis showed that active MMP-2 and -9 were independent predictors of late recurrent carotid artery stenosis (p<0.03 and p<0.001, respectively).

CONCLUSIONS

Higher plasma concentrations of active MMP-2 and -9 were associated with an increased risk of carotid restenosis with plaque recurrence.

Interposition grafts for difficult carotid artery reconstruction: a 17-year experience

Carotid interposition grafts (CIP) for carotid artery revascularization can be a viable alternative to carotid endarterectomy (CEA) or carotid artery stenting (CAS) for complex carotid disease. This is a retrospective review of the UCLA 17-year experience with CIP for carotid reconstruction. Carotid operations performed between 1988 and 2005 revealed 41 CIP procedures in 39 patients using polytetrafluoroethylene (PTFE, n = 31) or reversed greater saphenous vein (Vein) (n = 10). Perioperative data and long-term follow-up for each conduit were statistically compared. There were no significant differences in demographics, risk factors, operative indications, complications, or 30-day perioperative deaths. There was one postoperative stroke in each group, for an overall stroke rate of 4.9% (PTFE 3.2%, Vein 10%). There was one asymptomatic occlusion and there were two high-grade restenoses in the PTFE group compared with one asymptomatic occlusion and one high-grade restenosis in the Vein group. Overall primary patency was 90% and the assisted primary patency was 97% for the PTFE group (mean follow-up 50 months), whereas primary patency was 80% (mean follow-up 30 months) in the Vein group. CIP is a safe and effective technique with excellent long-term follow-up for complex carotid reconstruction when CEA or CAS may be contraindicated.

Techniques in carotid artery surgery

✓The major objective in carotid endarterectomy is to achieve safe and complete removal of intimal plaque and provide lasting, nonstenotic closure. Controversy exists as to which technical variation best achieves this. In this paper, the authors review the operative nuances and outcomes with conventional and eversion endarterectomy, with a focus on the latter. The views expressed reflect specific neurosurgical and vascular perspectives in the context of a multi-disciplinary stroke unit, where carotid stenosis is managed with all available open and endovascular means. The neurosurgical approach was almost entirely conventional endarterectomy with primary repair, while the vascular surgeons used the eversion method with few exceptions.

Surgery Insight: carotid endarterectomy--which patients to treat and when?

Over the past 15 years, we have witnessed a resurgence of surgery for prevention of ischemic stroke. Landmark trials including the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial have explored the role of carotid endarterectomy in this context, comparing the procedure with best medical treatment in patients with high-grade stenosis of the internal carotid artery and transient ischemic attack or minor nondisabling stroke in the same territory. Here, we discuss the lessons learnt from these trials, and review the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trial, which attempted to resolve the rather vexing issue of surgical treatment for patients with asymptomatic internal carotid artery stenosis. We also review the best medical treatment for patients undergoing carotid endarterectomy in the perioperative period, and examine the risk of ischemic stroke after CABG surgery, both when this procedure is performed alongside endarterectomy and when CABG surgery and endarterectomy are performed as a two-staged procedure.

Comparison of in-hospital outcomes of patients with versus without previous carotid endarterectomy undergoing carotid stenting (from the German ALKK CAS Registry)

Repeat carotid endarterectomy (CEA) for recurrent stenosis remains a challenging treatment option associated with high morbidity and mortality. Carotid artery stenting (CAS) is an attractive alternative management option for these patients. However, data about the effectiveness and safety of CAS in a large number of unselected patients are less known. We evaluated 3,070 patients who underwent CAS enrolled in a German registry from 1996 to 2006 at 31 sites. We compared clinical and angiographic features and in-hospital outcomes of patients with and without previous CEA who underwent CAS. Of 3,070 patients in the registry, 223 (7.3%) underwent CAS for restenosis after previous CEA. Median age was similar in patients with and without previous CEA (70 years, interquartile range 64 to 76 vs 71 years, interquartile range 65 to 76). Ipsilateral neurologic symptoms occurred in approximately 1/2 the patients in both groups. Other co-morbid conditions and angiographic or procedural factors did not differ between the 2 groups. In-hospital events including death (0% vs 0.4%), ipsilateral major stroke (1.4% vs 1.5%), death or major ipsilateral stroke (1.4% vs 1.7%), ipsilateral transient ischemic attack (1.9% vs 2.8%), myocardial infarction (0.4% vs 0.1%), and reintervention (0.7% vs 0.4%) were all low and not significantly different between those with and without previous CEA (p >0.05 for all comparisons). In conclusion, our data for a large number of patients who underwent CAS in a recent contemporary community-based practice attests to the low risk of periprocedural events in patients with recurrent stenosis after previous CEA. This low risk along with the less invasive nature of the procedure should make CAS an attractive and perhaps preferred option for the treatment of these patients.

Carotid angioplasty and stenting versus redo endarterectomy for recurrent stenosis

BACKGROUND

Carotid angioplasty and stent (CAS) is an alternative to redo carotid endarterectomy (RCEA) for recurrent carotid stenosis (RCS). The purpose of this study was to evaluate the outcomes of CAS in the treatment of RCS.

METHODS

In an 8-year period, all patients presenting for treatment of RCS were followed-up prospectively. Logistic regression analysis was performed to identify variables associated with unfavorable outcomes.

RESULTS

There were 45 CAS and 46 RCEA procedures performed in 75 patients. One patient in each group suffered a stroke. There were no deaths. The hospital length of stay was significantly shorter for CAS. Secondary recurrence was higher after RCEA (14% vs 6.1%) and failure to take beta-blockers was an independent predictor for multiple recurrences.

CONCLUSIONS

CAS is a safe and effective method to treat patients with RCS and may become the procedure of choice for this disease.

Carotid angioplasty and stent placement for restenosis after endarterectomy

INTRODUCTION

Recurrent carotid stenosis following endarterectomy is a common complication, and reoperation may be associated with increased morbidity. The goal of this study was to determine the procedural safety and long-term complication rates of carotid angioplasty and stenting for recurrent stenosis.

METHODS

Of 248 consecutive carotid angioplasty and/or stenting procedures performed at our institution between March 1996 and November 2005, 83 procedures for recurrent stenosis following endarterectomy were performed in 75 patients (mean age 68 years; 43 men, 32 women) without cerebral protection devices. The patients' medical records were retrospectively reviewed for vascular imaging reports and available clinical follow-up. Procedural and long-term complication rates were calculated.

RESULTS

Recurrent stenosis was reduced from a mean of 80.6% to no significant stenosis in 82 of 83 procedures. The procedural stroke rate was 3 out of 83 procedures (3.6%). The procedural transient ischemic attack (TIA) rate was 2 out of 83 procedures (2.4%). Mean follow-up was 22.4 months (range 0.1 to 86.7 months) with at least 6 months follow-up for 54 of 83 procedures (65%). There were five TIAs and no strokes on follow-up (new TIAs at 25.5 and 43.4 months; recurrent TIAs at 1, 11.1, and 12 months, all with normal angiograms). The composite 30-day stroke, myocardial infarction, or death rate was 5 of 83 procedures (6.0%).

CONCLUSION

In this series, angioplasty and stenting were effective in relieving stenosis secondary to recurrent carotid disease after endarterectomy, and have low rates of ischemic complications.

Endovascular and surgical management of carotid artery restenosis

Background. The incidence of recurrent carotid stenosis after primary endarterectomy ranges from 10-34%. We presented our four year experience and comparing reoperation versus endovascular treatment. Methods. In period from 2001 to 2005, 50 patients, 37 men and 13 women, were treated surgically and endovascular due to restenosis. Results. There were no minor or major stroke, death and myocardial infarction periprocedural and in first 30 days in either group. In endovascular group one patients 3,17% had transient ischemic attack and two patients 11,76% in surgical group. One patient died from myocardial infraction in follow up in surgical group. There were no restenosis >50% in endovascular group, two patients have restenosis >50% in surgical group. Conclusions. Endovascular treatment of carotid artery restenosis represents a safe and efficient way of treatment, connected with minor number of serious complications than redo operation.

Carotid angioplasty and stenting for postendarterectomy stenosis: Long-term follow-up

BACKGROUND

Carotid angioplasty and stenting (CAS) for recurrent stenosis after carotid endarterectomy (CEA) has been proposed as an alternative to redo CEA. Although early results are encouraging, the extended durability remains unknown. We present the long-term surveillance results of CAS for post-CEA restenosis.

METHODS

Between 1998 and 2004, 57 CAS procedures were performed in 55 patients (36 men) with a mean age of 70 years. The mean interval between CEA and CAS was 83 months (range, 6 to 245). Nine patients (16%) were symptomatic.

RESULTS

CAS was performed successfully in all patients. No deaths or strokes occurred. A periprocedural transient ischemic attack (TIA) occurred in two patients. During a mean follow-up of 36 months (range, 12 to 72 months), two patients exhibited ipsilateral cerebral symptoms (1 TIA, 1 minor stroke). In 11 patients (19%), in-stent restenosis (> or =50%) was detected post-CAS at month 3 (n = 3), 12 (n = 3), 24 (n = 2), 36 (n = 1), 48 (n = 1), and 60 (n = 1). The cumulative rates of in-stent restenosis-free survival at 1, 2, 3, and 4 years were 93%, 85%, 82%, and 76%, respectively. Redo procedures were performed in six patients, three each received repeat angioplasty and repeat CEA with stent removal. The cumulative rates of freedom from reintervention at 1, 2, 3, and 4 years were 96%, 94%, 90%, and 84%, respectively.

CONCLUSION

Carotid angioplasty and stenting for recurrent stenosis after CEA can be performed with a low incidence of periprocedural complications with durable protection from stroke. The rate of in-stent recurrent stenosis is high, however, and does not only occur early after CAS but is an ongoing process.

Restenosis after carotid endarterectomy

Multiple randomised trials over the last decade for both symptomatic and asymptomatic carotid stenosis have proven the efficacy of carotid endarterectomy (CE) in reducing the risk of stroke. The long-term patency of the carotid artery after CE is an important factor in the success of the operation. The incidence of recurrent carotid stenosis (excluding residual lesions) ranges from 1 to 37% with only 0-8% of patients having restenosis-related symptoms (1). Generally, recurrent carotid stenosis is attributed to myointimal hyperplasia during the early postoperative period (within 3 years) or recurrent atherosclerosis thereafter. The management of recurrent carotid stenosis after CE remains a dilemma. It is generally accepted that operation for significant recurrent carotid stenosis is indicated for symptomatic patients, and several authors also recommend CE for >80% asymptomatic recurrent stenosis. Treatment of recurrent carotid stenosis involves repeat endarterectomy with patch angioplasty, although more recently endovascular techniques have been used.

Cervical carotid revascularization: the case for carotid angioplasty with stenting

Carotid artery angioplasty with or without stent placement has evolved as an alternative to carotid endarterectomy, particularly for those patients in whom carotid endarterectomy is associated with a higher risk of complications. This article summarizes the selection criteria for participation in and the results of several carotid intervention trials, reviews the relative indications and limitations for both surgical and endovascular revascularization approaches, and describes the technique for and results associated with carotid stenting. The discussion is presented from the vantage of neurosurgeons who are experienced in both revascularization approaches.

Endovascular Treatment of In-Stent Restenosis After Carotid Artery Stenting: Immediate and Midterm Results

PURPOSE

To evaluate the immediate and midterm outcome and analyze the debris captured after repeat endovascular intervention for the treatment of in-stent restenosis after carotid artery stenting (CAS).

METHODS

Thirty-one consecutive patients (27 men; mean age 63.7+/-13.0 years, range 53- 81) underwent repeat endovascular intervention (balloon angioplasty and provisional stenting) for the treatment of 32 in-stent restenoses following CAS.

RESULTS

Procedural success was achieved in all patients. An additional stent was implanted in 10 (31%) cases. No procedural complication was observed. Filter analysis was performed in 17 (53%) procedures; on 12 (71%), macroscopically visible material was captured. The histomorphometric analysis performed on 6 (19%) filters showed fibrin nets entrapping erythrocytes, leucocytes, platelets, and in 2 cases, fibrous hypercellular tissue fragments. At 30 days and during follow-up (mean 17+/-5 months), no deaths, transient ischemic attacks, or strokes were observed. In 1 (3.1%) patient, asymptomatic recurrence of ISR was found on Doppler ultrasonography and successfully treated with balloon angioplasty.

CONCLUSION

Repeat endovascular intervention using balloon angioplasty with provisional stenting and routine cerebral protection appears to be a feasible, safe, and clinically effective strategy for the treatment of in-stent restenosis after CAS.

Safety and efficacy of reoperative carotid endarterectomy: A 14-year experience

BACKGROUND

Reoperative carotid endarterectomy (CEA) is an accepted treatment for recurrent carotid stenosis. With reports of a higher operative morbidity than primary CEA and the advent of carotid stenting, catheter-based therapy has been advocated as the primary treatment for this reportedly "high-risk" subgroup. This study reviews a contemporary experience with reoperative CEA to validate the high-risk categorization of these patients.

METHODS

From 1989 to 2002, 153 consecutive, isolated (excluding CEA/coronary artery bypass graft and carotid bypass operations) reoperative CEA procedures were reviewed. Clinical and demographic variables potentially associated with the end points of perioperative morbidity, long-term durability, and late survival were assessed with multivariate analysis.

RESULTS

There were 153 reoperative CEA procedures in 145 patients (56% men, 36% symptomatic) with an average age of 69 +/- 1.3 years. The average time from primary CEA (68% primary closure, 23% prosthetic, 9% vein patch) to reoperative CEA was 6.1 +/- 0.4 years (range, 0.3 to 20.4 years). At reoperation, patch reconstruction was undertaken in 93% of cases. The perioperative stroke rate was 1.9%, with no deaths or cardiac complications. Other complications included cranial nerve injury (1.3%) and hematoma (3.2%). Average follow-up after reoperative CEA was 4.4 +/- 0.3 years (range, 0.1 to 12.7 years), with an overall total stroke-free rate of 96% and a restenosis rate (>50%) by carotid duplex of 9.2%. Among variables assessed for association with restenosis after reoperative CEA, only younger age was found to be significant (66 +/- 2.5 years vs 70 +/- 0.7 years, P < .05). The all-cause long-term mortality rate was 29%. Multivariate analysis of long-term survival identified diabetes mellitus as having a negative impact (hazard ratio, 3.4 +/- 0.3, P < .05) and lipid-lowering agents as having a protective effect (hazard ratio, 0.42 +/- 0.4, P < .05) on survival.

CONCLUSION

Reoperative CEA is a safe and durable procedure, comparable to reported standards for primary CEA, for long-term protection from stroke. These data do not support the contention that patients who require reoperative CEA constitute a "high-risk" subgroup in whom reoperative therapy should be avoided.

Recurrent Carotid Artery Stenosis Following Endarterectomy: Natural History and Risk Factors

OBJECTIVES

To establish the incidence of restenosis (RES) following carotid endarterectomy (CEA) and evaluate clinical and technical factors related to its development.

DESIGN

Prospective non-randomised cohort study.

PATIENTS AND METHODS

Two hundred and twenty-four patients with 243 CEA between May 1998 and December 2002, were subjected to clinical and haemodynamic follow-up, median follow-up 23 months (1-56). There was selective use of a shunt (17.3%) and patch (61.7%). RES (> or =50%) and severe restenosis, > or =70%, (sRES) were defined as peak systolic velocities of > or =150 and > or =300cm/s (or > or =250cm/s with diastolic velocity >100cm/s), respectively. Rates of RES, symptom development and mortality were analysed using Kaplan-Meier curves. Cox's regression model (hazards ratio/95% CI) was used to evaluate prognostic factors.

RESULTS

We detected 13 sRES (5.3%) (median time 6.1 months) and 30 (12.3%) moderate stenosis (mRES) (median time 3.7 months). Cumulative freedom from sRES at 23 months was 94.2%. Five sRES detected in the first 45 days after the procedure were deemed to be residual restenosis (rRES). Five (38.4%) sRES were symptomatic, 15.3% progressed to occlusion. Patient survival was 98.0 and 96.4% at 12 and 24 months, respectively. Independent risk factors for sRES: female sex (HR: 3.3, 95% CI 1.1-10 p=0.04) and diabetes (HR: 4.5, 95% CI 1.4-13.9 p=0.008).

CONCLUSIONS

Carotid restenosis appears early, is usually low-grade and mostly asymptomatic. Although few stenoses progress to occlusion, women and diabetic patients were at highest risk.

Patient selection for revascularization in cervical carotid artery disease: angioplasty and stenting vs. endarterectomy

Cervical carotid stenosis is a major cause of stroke and disability. Although carotid endarterectomy is an established and effective treatment for some patients with carotid artery stenosis, angioplasty and stenting has emerged in recent years as a viable alternative, particularly for patients who may be less suited for surgery. This article reviews patient selection for the two alternative approaches. The authors review the findings of the major clinical trials of carotid endarterectomy, summarize the development of carotid angioplasty and stenting, and identify patient characteristics that may guide selection of surgical or endovascular treatment.

Impact of Carotid Artery Angioplasty and Stenting on Management of Recurrent Carotid Artery Stenosis

Citing the higher perioperative risk of redo carotid surgery, balloon angioplasty and stenting of the carotid artery (CAS) has been advocated for recurrent carotid stenosis (RCS). To examine the impact of CAS on the management and outcome of recurrent stenosis, a retrospective review of a prospectively compiled database was performed. From a registry of patients treated for carotid disease, 105 procedures were performed from 1992 to 2002 for RCS. For comparison, two study groups were examined. Time I consisted of 77 reoperations performed through 1998, before CAS was introduced at our institution. Time II included 12 reoperations and 16 CAS procedures performed for RCS from 1999 through 2002. Using perioperative stroke as a measure of outcome, the results for time II were poorer than for time I (7.2% vs. 5.2%, p = NS). Overall, the risk of perioperative stroke was the same for reoperation (5/89) and CAS (1/16) (5.6% vs. 6.3%, p = NS). Although not statistically significant, there was a trend toward a higher risk of perioperative stroke for patients treated with reoperation during the latter time period (8.3% vs. 5.2%, p = NS). This probably relates to the finding that during time II, CAS was most likely to be used in asymptomatic patients (68.6% vs. 41.7%, p = NS) with early (<3 years) RCS (87.5% vs. 41.7%, p= 0.01). No patient with asymptomatic, early RCS had a perioperative stroke with either surgery or CAS (0/35 cases, 0%). The presence of preoperative neurologic symptoms was significantly predictive of a perioperative stroke among all procedures performed for RCS (13.6% vs. 0%, p = 0.004). Contrary to suggestions that CAS might improve the management of RCS, a review of our data shows the overall risk of periprocedural stroke to be no better since CAS has become available. The bias for using CAS for asymptomatic myointimal hyperplastic lesions, and reoperation for frequently symptomatic late recurrent atherosclerotic disease, makes direct comparisons of the two techniques for treating RCS difficult. It is expected that the overall risk for redo carotid surgery will increase, as fewer low-risk patients will be receiving open procedures. However, the increased risk among symptomatic patients undergoing reoperation suggests that endovascular techniques should be investigated among this group of cases as well.

Carotid Artery Angioplasty for Restenosis Following Endarterectomy

INTRODUCTION

The higher complication rate associated with the surgical treatment of restenosis following carotid endarterectomy (CEA) has led several authors to advocate angioplasty as the treatment of choice in the management of restenosis. We describe our experience with internal carotid artery angioplasty for post-endarterectomy restenosis over 7 years.

PATIENTS AND METHODS

From January 1994 to April 2001, all patients with a >90% restenosis following CEA were considered for angioplasty. Thirty angioplasties were carried out in 25 patients, 80% (24/30), for asymptomatic recurrent stenosis. There was no difference between those who had intervention for recurrent stenosis (n=31) and those who did not (n=545) in age, sex, smoking status or incidence of diabetes or hypertension. A significantly greater number of patients who underwent angioplasty were hypercholesterolaemic (p<0.05, Chi-squared test).

RESULTS

Mean time from surgery to angioplasty was 13 months (range 1-23). Angioplasty was technically successful in 29 cases (97%). Three patients (10%) experienced transient neurological symptoms during the procedure. There were no strokes. Ninety-six percent (28/29) of patients were followed up with duplex scanning. Mean follow-up was 20 months (range 2-48). Three patients developed a greater than 90% restenosis.

CONCLUSION

Angioplasty is an acceptable alternative to surgery in the management of internal carotid artery restenosis following endarterectomy.