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

Cutting Balloon Angioplasty for Severe In-Stent Restenosis after Carotid Artery Stenting: Long-Term Outcomes and Review of Literature

PURPOSE

Cutting balloon-percutaneous transluminal angioplasty (CB-PTA) is a feasible treatment option for in-stent restenosis (ISR) after carotid artery stenting (CAS). However, the longterm durability and safety of CB-PTA for ISR after CAS have not been well established.

MATERIALS AND METHODS

We retrospectively reviewed medical records of patients with ISR after CAS who had been treated with CB-PTA from 2012 to 2021 in our center. Detailed information of baseline characteristics, periprocedural and long-term outcomes, and follow-up imaging was collected.

RESULTS

During 2012-2021, a total of 301 patients underwent CAS. Of which, CB-PTA was performed on 20 lesions exhibiting severe ISR in 18 patients following CAS. No patient had any history of receiving carotid endarterectomy or radiation therapy. These lesions were located at the cervical segment of the internal carotid artery (n=16), proximal external carotid artery (n=1), and distal common carotid artery (n=1). The median time interval between initial CAS and detection of ISR was 390 days (interquartile range 324-666 days). The follow-up period ranged from 9 months to 9 years with a median value of 21 months. Four patients (22.2%) were symptomatic. The average of stenotic degree before and after the procedure was 79.2% and 34.7%, respectively. Out of the 18 patients receiving CB-PTA, 16 (88.9%) did not require additional stenting, and 16 (88.9%) did not experience recurrent ISR during the follow-up period. Two patients who experienced recurrent ISR were successfully treated with CB-PTA and additional stenting. No periprocedural complication was observed in any case.

CONCLUSION

Regarding favorable periprocedural and long-term outcomes in our single-center experience, CB-PTA was a feasible and safe option for the treatment of severe ISR after CAS.

Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis

Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.

Treatment of the Carotid In-stent Restenosis: A Systematic Review

Background and Purpose: In-stent restenosis (ISR) after carotid artery stent (CAS) is not uncommon. We aimed to evaluate therapeutic options for ISR after CAS. Methods: We searched PubMed and EMBASE until November 2, 2020 for studies including the treatment for ISR after CAS. Results: In total, 35 studies, covering 1,374 procedures in 1,359 patients, were included in this review. Most cases (66.3%) were treated with repeat CAS (rCAS), followed by percutaneous transluminal angioplasty (PTA) (17.5%), carotid endarterectomy (CEA) (14.3%), carotid artery bypass (1.5%), and external beam radiotherapy (0.4%). The rates of stroke & TIA within the postoperative period were similar in three groups (PTA 1.1%, rCAS 1.1%, CEA 1.5%). CEA (2.5%) was associated with a slightly higher rate of postoperative death than rCAS (0.7%, P = 0.046). Furthermore, the rate of long-term stroke & TIA in PTA was 5.7%, significantly higher than rCAS (1.8%, P = 0.036). PTA (27.8%) was also associated with a significantly higher recurrent restenosis rate than rCAS (8.2%, P = 0.002) and CEA (1.6%, P < 0.001). The long-term stroke & TIA and recurrent restenosis rates showed no significant difference between rCAS and CEA. Conclusions: rCAS is the most common treatment for ISR, with low postoperative risk and low long-term risk. CEA is an important alternative for rCAS. PTA may be less recommended due to the relatively high long-term risks of stroke & TIA and recurrent restenosis.

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.

Meta-analysis of redo stenting versus endarterectomy for in-stent stenosis after carotid artery stenting

OBJECTIVE

The development of in-stent restenosis (ISR) hinders the long-term patency of carotid artery stenting (CAS), yet no optimal treatment has been established. In the present study, we compared the outcomes of redo CAS (rCAS) and carotid endarterectomy (CEA) for ISR.

METHODS

A systematic search using the terms "in-stent restenosis," "carotid endarterectomy," and "carotid artery stenting" was conducted in the PubMed, Embase, and Cochrane databases. Studies reporting perioperative stroke, death, and other important complications of rCAS or CEA for ISR after previous CAS with four or more patients were included. Pooled and sensitivity analyses were conducted to synthesize and compare estimates of the outcomes.

RESULTS

A total of 11 studies with 1057 patients who had undergone rCAS (n = 894) or CEA (n = 163) met the inclusion criteria. The CEA group had a significantly greater proportion of symptomatic patients (rCAS vs CEA, 30.4% vs 42.1%; P < .01). The duration from primary CAS to reintervention was relatively longer in the CEA group (rCAS vs CEA, median, 8.8 months [range, 3-26 months] vs 19.9 months [range, 0-54 months]). In the rCAS group, a greater proportion of patients had hypertension, hypercholesterolemia, and coronary artery disease and had received antiplatelet therapy before reintervention. Because of insufficient data or a low incidence, the only complications feasible for further analysis were restenosis, myocardial infarction, cranial nerve injury, and neck hematoma. No significant differences were found in the primary end point of mortality/stroke event-free rate (rCAS vs CEA, 99% vs 98%; P > .05) or other secondary end points (event-free restenosis, 100% vs 100%; event-free myocardial infarction, 100% vs 98%; event-free cranial nerve injury, 100% vs 98%; event-free neck hematoma, 100% vs 100% for rCAS vs CEA; P > .05 for all).

CONCLUSIONS

rCAS is commonly used to treat patients with severe and/or symptomatic ISR after primary CAS. Although the endovascular approach is less invasive, both rCAS and CEA can be performed safely with similar short- and midterm outcomes of stroke, death, and surgery-related complications.

A Review on the Comparison of Different Treatments for Carotid In-Stent Restenosis

Different treatment options for carotid in-stent restenosis (ISR) have been reported with good outcome, including carotid endarterectomy (CEA), repeated carotid angioplasty stenting (CAS) and percutaneous transluminal angioplasty (PTA) with drug-coated balloons (DCBs). However, the optimal treatment option for ISR has not yet been determined. A systematic literature search was performed in the databases of Medline, Embase, Cochrane library, and unpublished data from clinicaltrials.gov from 1990 to March 1, 2019. Studies were enrolled if they reported treatment strategies for carotid ISR treatment and met the inclusion criteria. After study inclusions, data were extracted and summarized. Totally 25 cross-sectional studies were included, containing 5 comparative studies, 16 studies using repeated PTA, and 4 studies adopting CEA treatment. Our study summarized the current available data, showing that all the studies could effectively relieve the carotid ISR by significantly improving the angiographic stenosis and decreasing the peak systolic velocity values. Meanwhile, CEA treatment had the best long-term effects in relieving restenosis, while re-PTA with stenting/balloon angioplasty had a certain rate of restenosis, ranging from 33% to 83%. Furthermore, re-PTA/stenting and balloon angioplasty treatment had less complications compared with CEA. Also, we analyzed the risk factors that might affect the long-term prognosis of carotid ISR patients. The therapeutic measures for carotid ISR had their own features, with CEA had the highest efficacy while re-PTA/stenting and balloon angioplasty were with less complications. More large-scale comparative clinical studies are needed to further ascertain the best strategies.

Management of extracranial carotid artery disease

Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.

A technical strategy for carotid artery stenting: suboptimal prestent balloon angioplasty without poststenting balloon dilatation

BACKGROUND

Traditional carotid artery stenting (CAS) consists of predilatation, optional deployment of embolic protection devices, stenting, and poststent angioplasty. Each step carries a risk of thromboembolism.

OBJECTIVE

To design a new and simplified procedural protocol, suboptimal balloon angioplasty without routine poststenting balloon dilatation, and to describe the efficacy this protocol in terms of procedural risks and angiographic and clinical outcomes.

METHODS

Over a period of 6 years, 161 carotid artery stenoses in 156 consecutive patients were treated by CAS with embolic protection devices. Among them, 110 lesions in 107 patients (68.3%) were treated by our simplified method (symptomatic, > 50% stenosis; asymptomatic, > 70% stenosis). Overall, 98 lesions (88.3%) had severe stenosis (> 70%).

RESULTS

The mean stenosis was reduced from 77% to 10% after CAS. A persistent neurological deficit developed in 2 patients from thromboembolism. Hemodynamic insufficiency developed in 14 lesions during CAS (12.7%). The ipsilateral stroke and mortality rate was 4.5% within 1 month after CAS (asymptomatic, 3.6%; symptomatic, 4.8%). Over a mean of 19 months of follow-up, additive angioplasty was performed in 2 patients as a result of progressive restenosis (≥ 50%). A comparison of the balloon sizes of the prestent angioplasty for group 1 (balloon, ≤ 4 mm) and group 2 (balloon, ≥ 5 mm) showed no difference in restenosis between the groups at 15 months of follow-up after CAS.

CONCLUSION

Our CAS technique with suboptimal prestenting angioplasty without routine use of poststenting dilatation is safe, simple, and efficient with acceptable risks.

Follow-up Outcomes of Self-Expanding Stents for Carotid Artery Angioplasty at a Single Hospital

Carotid artery angioplasty and stent placement (CASP) is widely accepted as a valuable alternative to carotid endarterectomy, particularly among high-risk patient populations. We analyzed the follow-up data of patients who underwent CASP with self-expanding stents for carotid lesions. Since 2001, self-expanding stents have been deployed in 59 lesions in 56 patients. Forty-seven patients were male, and nine were female. The median age was 73 years, ranging 50 to 83 years. There were 31 asymptomatic lesions and 28 symptomatic lesions. The median follow-up period was 27 months, ranging six to 102 months. All lesions received stents and technical success was achieved in 58 (98.3%) out of 59 lesions. The 30-day transient ischemic attack rate was 8.6%, the stroke rate was 3.4%, and the death rate was 0%. No ischemic attack was observed on the ipsilateral side after 30 days. Recurrent stenosis (>50%) was observed in three patients (5.1%) and in two (3.4%) of these, revascularization was performed. Kaplan-Meier analysis showed that the rates for one year and two year freedom from any stroke or death were 93.1% and 90.9%, respectively. The incidence of recurrent carotid stenosis is acceptably low after CASP. CASP is effective to prevent ipsilateral ischemic stroke in symptomatic and asymptomatic patients.

Carotid artery interventions for restenosis after prior stenting: is it different from interventions of de novo lesions? Results from the carotid artery stent (CAS)--registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

OBJECTIVE

To compare characteristics and outcome of patients with re-stenoses after prior carotid artery stenting (CAS) treated with repeat carotid interventions (Re-CI) with CAS for de novo lesions.

BACKGROUND

The treatment of re-stenosis is a major problem in vascular interventions. Patients with re-stenoses after prior CAS treated with Re-CI are not well defined.

METHODS

We analyzed data from the prospective ALKK CAS Registry.

RESULTS

Out of 3,817 CAS procedures 95 were intended in 93 patients (2.5%) for a restenosis after prior CAS and 3,722 CAS in 3,655 patients (97.5%) for a de novo stenosis. There was no difference in age (p = 0.302) or distribution of gender (p = 0.545) between the two groups. Patients treated for a restenosis after CAS were less likely to be treated for a symptomatic lesion (22.7 vs. 40.1%, p = 0.001). Coronary heart disease (p = 0.017), peripheral arterial disease (p < 0.001) as well as diabetes mellitus (p = 0.004) were more prevalent in the restenosis group. Lesions were less complicated in restenosis patients, with less ulcers (7.4 vs. 19.9%, p = 0.003) and less severe calcifications (7.4 vs. 23.6%, p < 0.001). The intended interventions were more often not performed in the Re-CI group (9.5 vs. 3.3%; p = 0.001). In-hospital, the stroke or death rate was 0% in the Re-CI group as compared to 3.1% in the de novo group (p = 0.115).

CONCLUSIONS

Patients treated with Re-CI for repeat stenoses after prior CAS represent 2.5% of current CAS patients. Although representing a subgroup with more concomitant diseases, Re-CI seems to be associated with lower event rates as compared to CAS for de novo lesions.

Results using a self-expanding stent alone in the treatment of severe symptomatic carotid bifurcation stenosis

Object

Conventional endovascular therapy for carotid stenosis involves placement of an embolic protection device followed by stent insertion and angioplasty. A simpler approach may be placement of a stent alone. The authors determined how often this approach could be used to treat patients with carotid stenosis, and assessed which factors would preclude this approach.

Methods

Over a period of 6 years, 97 patients with symptomatic carotid stenosis were treated with the intention of using a “stent-only” approach. Arteries in 77 patients (79%) were treated with stents alone, 13 required preinsertion balloon dilation, 6 postinsertion dilation, and 1 both pre- and postinsertion dilation.

Results

The mean stenosis according to North American Symptomatic Carotid Endarterectomy Trial criteria was reduced from 82 to 40% in the stent-only group and from 89 to 37% in the stent and balloon angioplasty group. The 30-day stroke and death rate was 7.2%. Patients were followed for a mean of 15 months. In the stent-alone group, the mean preoperative Doppler peak systolic velocity (PSV) was 409 cm/second, with an internal carotid artery/common carotid artery (ICA/CCA) ratio of 7.2. At follow-up review, the PSV decreased to 153 cm/second and the ICA/CCA ratio to 2.1. In the angioplasty group the mean preoperative PSV was 496 cm/second and the ICA/CCA ratio was 9.2, decreasing to 163 cm/second and 2, respectfully, at follow-up evaluation. Restenosis occurred in 12.8% of patients at 6 months and in 15.9% at 1 year. One stroke occurred during the follow-up period in each group. Using multivariable analysis, factors precluding the “stent-only” approach were as follows: severity of stenosis, circumferential calcification, and no history of hyperlipidemia.

Conclusions

Balloons may not be required to treat all patients with carotid stenosis. A stent alone was feasible in 79% of patients, and 79% of patients were alive and free from ipsilateral stroke or restenosis at 1 year. Restenosis rates with this approach are higher than with conventional angioplasty and stent insertion. Carotid arteries with very severe stenoses (> 90%) and circumferential calcification may be more successfully treated with angioplasty combined with stent placement.

Diagnosis and invasive management of carotid atherosclerotic stenosis

Carotid atherosclerotic stenosis is a known risk factor for ischemic stroke. Methods for detecting stenosis and revascularization abound. The objective of this review was to summarize the evidence for diagnosing carotid artery stenosis and treating symptomatic or asymptomatic stenosis with endarterectomy or stenting. An Ovid MEDLINE search identified relevant original research published between 1990 and 2006. With acceptable surgical risk and patient life expectancy, carotid endarterectomy is clearly indicated for symptomatic stenosis of more than 70%. Carotid endarterectomy is also recommended for symptomatic stenosis of more than 50%, but the health impact is less compelling. The US Food and Drug Administration has approved several stents for a subset of patients with carotid stenosis. Randomized comparisons of endarterectomy vs stenting have been performed in average- and high-risk patients with asymptomatic and symptomatic carotid artery stenosis with mixed results.