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

Abstract

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.

Keywords: carotid artery stent (CAS); carotid endarterectomy (CEA); in-stent restenosis (ISR); percutaneous transluminal angioplasty (PTA); treatment.

Figure 1

The preferred reporting items for systematic reviews and meta-analyses flowchart of the study selection.

Figure 2

The imaging techniques and indications in the 35 studies. (A) Imaging techniques used for the diagnosis of ISR. (B) Criteria for the treatment of ISR. Asterisks (^*) indicate a category of ISR not reported in the studies. (C) Thresholds of PSV, EDV, and ICA/CCA the in diagnosis of ISR. Sym, symptomatic; Asym, asymptomatic; DUS, duplex ultrasonography; DSA, digital subtraction angiography; CTA, CT angiography; MRA, MR angiography; EDV, end diastolic velocity; PSV, peak systolic velocity; ICA/CCA, internal to common carotid artery peak systolic velocity ratio.