A Propensity Matched Comparison for Open and Endovascular Treatment of Post-carotid Endarterectomy Restenosis

[Redo surgery of carotid arteries in patients with contraindications to carotid angioplasty and stenting]

AIM

The study was aimed at analysing the in-hospital results of carotid re-endarterectomy and plasty of the zone of reconstruction with a biological patch in patients with haemodynamically significant restenosis and contraindications to carotid angioplasty with stenting.

PATIENTS AND METHODS

During the period from 2008 to 2019, we operated on a total of 22 patients presenting with carotid restenosis and found to have contraindications to carotid angioplasty with stenting (an extended lesion, unstable neointima, calcification, pronounced tortuosity). Carotid re-endarterectomy was performed according to the classical technique. The time period after the first intervention to regression of pathology amounted to 48.5±21.3 months. All patients with clinical manifestations of angina pectoris were at the preoperative stage subjected to coronarography, as a result of which in one case a hybrid intervention was performed in the scope of percutaneous coronary intervention and carotid endarterectomy. The endpoints included death, myocardial infarction, acute impairment of cerebral circulation, and lesions of craniocerebral nerves.

RESULTS

Carotid re-endarterectomy was most often carried out according to the classical technique with plasty of the zone of reconstruction using a xenopericardial patch. Only in 1 case it was required to perform eversion carotid re-endarterectomy due to tortuosity of the internal carotid artery. During the in-hospital postoperative period no lethal outcomes, myocardial infarctions, nor haemorrhagic complications were registered. One patient was found to develop acute impairment of cerebral circulation. The most frequent complication was unilateral laryngeal paresis caused by lesions of craniocerebral nerves (n=3; 13.6%), with reversible neurological deficit. No cases of either thrombosis/restenosis or elevated pressure gradient in the area of implantation of the xenopericardial patch were revealed. The composite endpoint amounted to 18.2% (n=4).

CONCLUSION

The classical carotid re-endarterectomy was not accompanied by cases of thrombosis and restenosis during either the in-hospital or remote period of follow up, however turned out to be associated with a high frequency of the development of complications such as acute impairment of cerebral circulation and lesions of craniocerebral nerves.

Ipsilateral carotid bypass outcomes in hostile neck anatomy

OBJECTIVE

To determine differences in outcomes among patients undergoing ipsilateral carotid bypass with hostile or normal neck anatomy.

METHODS

Single-center retrospective review of all ipsilateral extracranial carotid bypasses performed between 1998 and 2018.

RESULTS

Forty-eight patients underwent ipsilateral carotid bypass from the common carotid artery to either the internal carotid artery or carotid bifurcation during the study period. Seven patients were excluded owing to either a lack of follow-up or missing data. The indications for intervention included infected patches, aneurysmal degeneration, symptomatic and asymptomatic stenosis or restenosis, carotid body tumors, neck malignancy, and trauma. In 25 procedures (61%), there was a hostile neck anatomy defined as a prior history of external beam neck irradiation or neck surgery. Among this group, 12 pectoralis muscle flaps were performed for reconstructive coverage. Conduits included polytetrafluorethylene (n = 21), great saphenous vein (n = 9), superficial femoral artery (n = 7) and arterial homograft (n = 4). All superficial femoral artery conduits were used in the hostile neck group (P = .03). The overall mean time of follow-up was 22 months, with all bypasses remaining patent with no significant clinical stenosis. The 30-day ipsilateral stroke and myocardial infarction rates were 4.88% each, all within the hostile neck group, with no 30-day mortalities for the entire cohort. One-third of the muscle flaps were performed in the setting of infected patches (P = .02) with no significant differences in perioperative outcomes with use. The overall median hospital length of stay was significantly increased in patients receiving muscle flap coverage (3.0 vs 7.0 days; P = .04).

CONCLUSIONS

In patients with a complex carotid pathology, ipsilateral carotid bypass is an effective solution for carotid reconstruction. Different conduits should be used depending on the indication. Muscle flap coverage should be considered in hostile settings when primary wound closure is not feasible.

Results of carotid artery stenting. Lessons learned in a Belgian 'real world' practice

OBJECTIVE/BACKGROUND

Carotid artery stenting (CAS) is a valuable solution for the treatment of carotid artery stenosis in a high-risk patient population for carotid endarterectomy (CEA). In literature however, there are concerns about the death and stroke rates of CAS in the 'real world' practice. Since Belgium is a small country with a broad offer of medical care, and there is no reimbursement for CAS, only small numbers of patients can be treated per vascular department.

METHODS

In our department 45 CAS were performed from January 2006 until May 2018. Patient characteristics, indication for treatment and choice of treatment, minor stroke, major stroke and death rates were analyzed retrospectively.

RESULTS

Of these patients 8/45 (18%) had a symptomatic carotid artery stenosis and 37/45 (82%) had an asymptomatic stenosis. A total minor stroke rate of 3/45 (6.6%) was recorded, but no major stroke (0%) or death (0%). Of the 37 patients who were asymptomatic at the start, 1 suffered a minor stroke (1/37, 2.7%) peri-operatively.

CONCLUSION

Real world data from a low volume center show that CAS performed in patients with high risk for CEA yields acceptable outcome that is comparable to the literature. Since CAS is a delicate procedure we advice to centralize the procedure to an dedicated experienced interventionalist and to perform rigorous quality control of your 'real world' data.

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.

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.

Treatment of Carotid Restenoses after Endarterectomy: A Retrospective Monocentric Study

BACKGROUND

To compare the different techniques for the treatment of carotid restenosis after carotid artery endarterectomy (CAE).

METHODS

Among 1,218 carotid surgeries carried out in our center between January 2010 and November 2017, 45 procedures were performed for carotid restenosis after CAE, including 11 by iterative conventional surgery and 34 with endovascular techniques (7 transluminal angioplasties alone [TLA], 9 carotid artery stenting [CAS], and 18 angioplasties with active balloons [drug-coated balloon {DCB}]). Perioperative data (cumulated rate of morbimortality [CRMM], duration of hospitalization) and postoperative results (survival, symptomatic restenoses > 50% or asymptomatic stenoses > 70% on ultrasound, reinterventions) were collected retrospectively and analyzed with Fisher's exact test. The long-term results were estimated according to the Kaplan-Meier estimator and were compared with the log rank test (P < 0.05 was regarded as significant).

RESULTS

There was one secondary death due to a massive postoperative stroke in the endovascular (ENDO) group. No significant difference regarding CRMM (2.9%, P = 0.756) between the iterative conventional surgery (open surgery; OS) and the ENDO groups of was observed. Three hematomas were found in the OS group versus one in the ENDO group (P = 0.04). The length of hospital stay was shorter in the ENDO group (P < 0.001). No difference was found between the ENDO group and the OS group regarding the two-year survival or the survival without recurrent restenosis (86 vs. 100%, log rank = 0.804, and log rank = 0.114). There were 5 restenoses >70% and two reinterventions in the ENDO group (P > 0.05). The comparison of the different endovascular techniques did not show significant differences regarding the CRMM, the one-year overall survival, the survival without recurrent restenosis, or the survival without reintervention (89% in the DCB and CAS groups vs. 100% in the percutaneous transluminal angioplasty [PTA] group, log rank = 0.286; 87% in the DCB group vs. 100% in the PTA and CAS groups, log rank = 0.137; and 94% in the DCB group vs. 100% in the PTA and CAS groups, log rank = 0.585, respectively).

CONCLUSIONS

In our experience, endovascular procedures are equivalent to iterative conventional surgery for the treatment of carotid restenoses in terms of major complications, news restenoses, or survival with less hematoma and a shorter duration of hospitalization. We however could not identify the best endovascular strategy in this indication, and a controlled study comparing the various endovascular strategies is proposed.

Long-term outcomes of open and endovascular treatment of recurrent carotid artery stenosis - a 16-year retrospective single centre case series

Background: The aim of this study is to evaluate perioperative as well as long-term outcomes in patients operated with carotid endarterectomy (CEA) or stenting (CAS) due to symptomatic or asymptomatic high-grade restenosis of the internal carotid artery (ICA). Patients and methods: In a retrospective analysis of our electronic database including 2980 patients who underwent carotid endarterectomy or stenting due to a symptomatic or asymptomatic high-grade stenosis of the ICA, between 2000 and 2016, we enrolled 111 patients with recurrent ICA stenosis. Results: An ipsilateral 2nd time restenosis (> 80 % in the asymptomatic and > 50 % in the symptomatic patients according to NASCET criteria) of ICA was detected in 13 patients (12 %); 3 of them were symptomatic. These patients were managed with either CEA (n = 5/38 %) or CAS (n = 8/62 %) with no perioperative stroke or death. The stroke-free survival rates at 2 and 8 years for CEA were 98 % and 98 % versus 100 % and 100 % for CAS respectively (P = .271). The type of the initial procedure (patch, CAS or interposition) did not play any significant role for the development of a 2nd time restenosis (P = .841). Conclusions: Redo-CEA/CAS seem to have similar results as primary procedures (as reported in the literature) with favorable periprocedural and long-term outcomes.

Management of De Novo Carotid Stenosis and Postintervention Restenosis-Carotid Endarterectomy Versus Carotid Artery Stenting-a Review of Literature

The current literature indicates carotid endarterectomy (CEA) as the preferred treatment for symptomatic, moderate to severe carotid artery stenosis. However, recommendations for the management of acute tandem stenosis and complete occlusion, as well as postintervention restenosis of the carotid artery, remain controversial. Here, we review the literature evaluating these conditions and provide suggestions for clinical decision-making. Acute tandem stenosis or occlusion of the common and internal carotid arteries may be treated with angioplasty alone, reserving carotid artery stenting (CAS) or CEA for severe and complex cases. Patients who underwent CEA and developed ipsilateral restenosis may be subjected to angioplasty followed by CAS, which carries a lower risk of cranial nerve injury and subsequent restenosis of the artery. For post-CAS restenosis, current evidence recommends angioplasty and CAS for the management of moderate stenosis and CEA for severe stenosis of the carotid artery. Given the lack of level 1 evidence for the management of these conditions, the abovementioned recommendations may assist clinical decision-making; however, each case and its unique risks and benefits need to be assessed individually. Future studies evaluating and defining the risks and benefits of specific treatment strategies, such as CEA and CAS, in patients with acute tandem stenosis, occlusion, and postintervention restenosis of the carotid artery need to be conducted.