Anatomical and Technical Factors Influence the Rate of In-Stent Restenosis following Carotid Artery Stenting for the Treatment of Post-Carotid Endarterectomy Stenosis

Abstract

Background: Carotid artery stenting (CAS) has been advocated as an alternative to redo surgery for the treatment of post-carotid endarterectomy (CEA) stenosis. This study analyzed the efficacy of CAS for post-CEA restenosis, focusing on an analysis of technical and anatomical predictive factors for in-stent restenosis.

Methods: We performed a retrospective monocentric study. We included all patients who underwent CAS for post-CEA restenosis at our institution from July 1997 to November 2013. The primary endpoints were the technical success, the presence of in-stent restenosis >50% or occlusion, either symptomatic or asymptomatic, during the follow-up period, and risk factors for restenosis. The secondary endpoints were early and late morbidity and mortality (TIA, stroke, myocardial infarction, or death).

Results: A total of 153 CAS procedures were performed for post-CEA restenosis, primarily because of asymptomatic lesions (137/153). The technical success rate was 98%. The 30-day perioperative stroke and death rate was 2.6% (two TIAs and two minor strokes), and rates of 2.2% (3/137) and 6.2% (1/16) were recorded for asymptomatic and symptomatic patients, respectively. The average follow-up time was 36 months (range, 6-171 months). In-stent restenosis or occlusion was observed in 16 patients (10.6%). Symptomatic restenosis was observed in only one patient. We found that young age (P = 0.002), stenosis > 85% (P = 0.018), and a lack of stent coverage of the common carotid artery (P = 0.006) were independent predictors of in-stent restenosis.

Conclusion: We identified new risk factors for in-stent restenosis that were specific to this population, and we propose a technical approach that may reduce this risk.

Fig 1. Lesion characteristics.

Dissection, calcification, hypodensity and ulceration.

Fig 2. location of lesion.

CCA = common carotid artery, ICA = internal carotid artery.

Fig 3. probability of in-stent restenosis or occlusion.

Kaplan-Meier curve.

Fig 4. in-stent restenosis: restenosis on CCA after shortening of the carotid wall stent.

A: CAROTID WALLSTENT 7–40 for a restenosis post CEA. B: shortening of the stent and early in-stent restenosis on CCA. The arrow is on the initial stent positioning.