Carotid artery stenting outcomes are equivalent to carotid endarterectomy outcomes for patients with post-carotid endarterectomy stenosis

The preoperative triglyceride-glucose index has a positive effect on predicting the risk of short-term restenosis after carotid artery stenting: a retrospective cohort study

Background

Increasing evidence suggests that insulin resistance is linked to cardiovascular disease and atherosclerosis. The triglyceride-glucose (TyG) index has proven to be a convincing marker to quantitatively evaluate insulin resistance. However, there is no relevant information about the relationship between the TyG index and restenosis after carotid artery stenting.

Methods

A total of 218 patients were enrolled. Carotid ultrasound and computed tomography angiography were used to evaluate in-stent restenosis. A Kaplan-Meier analysis and Cox regression method were performed to analyze the correlation between TyG index and restenosis. Schoenfeld residuals were used to determine the proportional-hazards assumption. A restricted cubic spline method was used to model and visualize the dose-response relationship between the TyG index and the risk of in-stent restenosis. Subgroup analysis was also performed.

Results

Thirty-one participants (14.2%) developed restenosis. The preoperative TyG index had a time-varying effect on restenosis. Within 29 months post-surgery, an increasing preoperative TyG index was linked to a significant increased risk of restenosis (hazard ratio: 4.347; 95% confidence interval 1.886-10.023). However, after 29 months, the effect was decreased, although not statistically significant. The subgroup analysis showed that the hazard ratios tended to be higher in the age ≤ 71 years subgroup (p < 0.001) and participants with hypertension (p < 0.001).

Conclusion

The preoperative TyG index was significantly associated with the risk of short-term restenosis after CAS within 29 months post-surgery. The TyG index may be employed to stratify patients based on their risk of restenosis after carotid artery stenting.

Short- and Mid-Term Outcomes of Stenting in Patients with Isolated Distal Internal Carotid Artery Stenosis or Post-Surgical Restenosis

The aim was to evaluate the outcome of stenting in patients with isolated distal internal carotid artery (ICA) stenosis or post-surgical restenosis, as no data are currently available in the literature. Sixty-six patients (men, N = 53; median age: 66 [IQR, 61–73] years) with ≥50% distal ICA (re)stenosis were included in this single-center retrospective study. The narrowest part of the (re)stenosis was at least 20 mm from the bifurcation in all patients. Patients were divided into two etiological groups, atherosclerotic (AS, N = 40) and post-surgical restenotic (RES, N = 26). Postprocedural neurological events were observed in two patients (5%) in the AS group and in two patients (7.7%) in the RES group. The median follow-up time was 40 (IQR, 18–86) months. Three patients (7.5%) in the AS group had an in-stent restenosis (ISR) ≥ 50%, but none in the RES group. Three patients (7.5%) in the AS group and seven patients (26.9%) in the RES group died. None of the deaths in the RES group were directly related to stenting itself. The early neurological complication rate of stenting due to distal ICA (re)stenoses is acceptable. However, the mid-term mortality rate of stenting for distal ICA post-surgical restenoses is high, indicating the vulnerability of this subgroup.

Nonfasting Triglyceride as an Independent Predictor of Carotid Restenosis After Carotid Endarterectomy or Carotid Artery Stenting

OBJECTIVE

Nonfasting serum triglyceride (TG) level is attracting more and more attention as an atherosclerosis-promoting factor. However, no study has investigated the relationships between nonfasting TG levels and carotid restenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS). This study was conducted to investigate if nonfasting TG levels can be used to assess a risk for carotid restenosis after CEA or CAS.

METHODS

This was a single-center retrospective study. We reviewed 201 consecutive primary carotid artery revascularization procedures (39 CEAs and 162 CASs), which were performed from 2008 to 2018 for 179 patients (163 men and 16 women) with atherosclerotic carotid stenosis, and were followed up for at least 1 year. Clinical variables including nonfasting lipid profiles and findings of magnetic resonance plaque imaging were compared between groups with and without postprocedural carotid restenosis (≥50% stenosis on ultrasonography).

RESULTS

During a mean follow-up period of 1413 days, 24 of 201 carotid stenosis procedures (11.9%) suffered restenosis after successful revascularization procedures. Multivariate analyses demonstrated that nonfasting TG level was the only independent risk factor of postprocedural restenosis. The receiver operating characteristic curve analyses revealed that a cutoff value of nonfasting TG to discriminate postprocedural carotid restenosis was 127.5 mg/dL, which was much lower than the upper limit of normal.

CONCLUSIONS

This study showed that nonfasting TG level may be a useful marker to predict carotid restenosis after CEA or CAS, and could be a new therapeutic target to prevent carotid restenosis after revascularization procedures.

Outcomes of transfemoral carotid artery stenting and transcarotid artery revascularization for restenosis after prior ipsilateral carotid endarterectomy

OBJECTIVE

Restenosis after carotid endarterectomy (CEA) poses unique therapeutic challenges, with no specific guidelines available on the operative approach. Traditionally, transfemoral carotid artery stenting (TfCAS) has been regarded as the preferred approach to treating restenosis after CEA. Recently, transcarotid artery revascularization with a flow-reversal neuroprotection system (TCAR) has gained popularity as an effective alternative treatment modality for de novo carotid artery stenosis. The aim of the present study was to compare the contemporary perioperative outcomes of TfCAS and TCAR in patients with prior ipsilateral CEA.

METHODS

The Vascular Quality Initiative database was reviewed for patients who had undergone TfCAS and TCAR for restenosis after prior ipsilateral CEA between January 2016 and August 2020. The primary outcome was the 30-day composite outcome of stroke and death. The secondary outcomes included 30-day stroke, transient ischemic attack (TIA), myocardial infarction (MI), death, and composite 30-day outcomes of stroke, death, and TIA, stroke and TIA, and stroke, death, and MI. Multivariable logistic regression models were used to evaluate the outcomes of interest after adjustment for potential confounders and baseline differences between cohorts.

RESULTS

Of 3508 patients, 1834 and 1674 had undergone TfCAS and TCAR, respectively. The TCAR cohort was older (mean age, 71.6 years vs 70.2 years; P < .001) and less likely to be symptomatic (27% vs 46%; P < .001), with a greater proportion taking aspirin (92% vs 88%; P = .001), a P2Y12 inhibitor (89% vs 80%; P < .001), and a statin (91% vs 87%; P = .002) compared with the TfCAS cohort. Perioperatively, the TCAR cohort had had lower 30-day composite outcomes of stroke/death (1.6% vs 2.7%; P = .025), stroke/death/TIA (1.8% vs 3.3%; P = .004), and stroke/death/MI (2.1% vs 3.2%; P = .048), primarily driven by lower rates of stroke (1.3% vs 2.3%; P = .031) and TIA (0.2% vs 0.7%; P = .031). Among asymptomatic patients, the incidence of stroke (0.6% vs 1.4%; P = .042) and the composite of stroke/TIA (0.8% vs 1.8%; P = .036) was significantly lower after TCAR than TfCAS, and TCAR was associated with a lower incidence of TIA (0% vs 1%; P = .038) among symptomatic patients. On adjusted analysis, the TCAR cohort had lower odds of TIA (adjusted odds ratio, 0.17; 95% confidence interval, 0.04-0.74; P = .019).

CONCLUSIONS

Among patients undergoing carotid revascularization for restenosis after prior ipsilateral CEA, TCAR was associated with decreased odds of 30-day TIA compared with TfCAS. However, the two treatment approaches were similarly safe in terms of the remaining perioperative outcomes, including stroke and death and stroke, death, and MI. Our results support the safety and efficacy of TCAR in this subset of patients deemed at high risk of reintervention.

Dysregulation of lncRNA SNHG1/miR-145 axis affects the biological function of human carotid artery smooth muscle cells as a mechanism of carotid artery restenosis

Carotid angioplasty and stenting have developed into reliable options for patients with carotid stenosis. However, postoperative restenosis remains a serious and unresolved problem. Restenosis is partly caused by the proliferation of vascular smooth muscle cells. As certain long non-coding RNAs (lncRNAs) affect cell proliferation and migration, the present study aimed to investigate them as novel biomarkers for restenosis development and to further reveal the potential underlying mechanisms. The expression of lncRNA small nucleolar RNA host gene 1 (SNHG1) and microRNA145 (miR-145) in human carotid artery smooth muscle cells (hHCtASMCs) was analyzed using reverse transcription-quantitative PCR. In addition, a luciferase reporter assay was performed to investigate the interaction between SNHG1 and miR-145. The effects of the SNHG1/miR-145 axis on the proliferation and migration of hHCtASMCs were evaluated by Cell Counting Kit-8 and Transwell assays. Serum SNHG1 and miR-145 expression levels were increased and decreased, respectively, in patients with restenosis (all P<0.001). High SNHG1 and low miR-145 were identified as risk factors for restenosis onset (all P<0.01). Furthermore, decreasing SNHG1 expression levels in hHCtASMCs inhibited cell proliferation and migration. The luciferase reporter assay and expression results demonstrated that miR-145 may be a target of SNHG1 and mediated the effects of SNHG1 on hHCtASMC proliferation and migration. The results obtained suggested that abnormal expression of SNHG1 and miR-145 may be risk factors for restenosis. The present study revealed that the SNHG1/miR-145 axis regulates hHCtASMC proliferation and migration, indicating its potential for restenosis prevention and treatment.

Long non-coding RNA cyclin-dependent kinase inhibitor 2B antisense ribonucleic acid 1 is associated with in-stent restenosis and promotes human carotid artery smooth muscle cell proliferation and migration by sponging miR-143-3p

Carotid angioplasty and stenting (CAS) is an efficient therapeutic approach for carotid stenosis. However, in-stent restenosis (ISR) frequently occurs and seriously affects the therapeutic efficacy of CAS. Certain non-coding (nc)RNAs serve potential roles in ISR development and progression. Thus, the goals of the present study were to investigate novel biomarkers for ISR development and to further uncover the mechanisms underlying the progression of ISR. The expression of long ncRNA cyclin-dependent kinase inhibitor (CDKN)2B-antisense 1 (AS1) and microRNA (miR)-143-3p in patients with ISR and human carotid artery smooth muscle cells (hHCtASMCs) was analyzed using reverse transcription-quantitative PCR. A luciferase reporter assay was performed to examine the interaction between CDKN2B-AS1 and miR-143-3p. The effects of the CDKN2B/miR-143-3p axis on hHCtASMC proliferation and migration were assessed using Cell Counting Kit-8 and Transwell assays. The results indicated that serum CDKN2B-AS1 was increased and miR-143-3p was decreased in patients with ISR as compared with that in patients with no ISR (all P<0.001). CDKN2B-AS1 and miR-143-3p were identified as risk factors for ISR onset (all P<0.05) and knockdown of CDKN2B-AS1 in hHCtASMCs led to inhibited cell proliferation and migration. Furthermore, the luciferase reporter assay and expression analysis indicated that miR-143-3p is a target of CDKN2B-AS1 and may mediate the effects of CDKN2B-AS1 on hHCtASMC proliferation and migration. In conclusion, dysregulation of CDKN2B-AS1 and miR-143-3p may represent risk factors for the occurrence of ISR. The in vitro results suggested that the CDKN2B-AS1/miR-143-3p axis may regulate the proliferation and migration of hHCtASMCs, indicating its potential to be developed as a target for preventative measures and therapies for ISR.

Duplex ultrasound findings and clinical outcomes of carotid restenosis after carotid endarterectomy

This study aimed to describe the duplex ultrasound (DUS) findings associated with carotid restenosis after carotid endarterectomy (CEA) and to determine whether carotid restenosis is associated with the clinical outcomes of CEA. Between January 2007 and December 2016, a total of 660 consecutive patients who underwent 717 CEAs were followed up at our hospital with DUS surveillance for at least 3 years after CEA. These patients were analyzed retrospectively for this study. Following CEA, restenosis was defined as the development of ≥50% stenosis, diagnosed on the basis of DUS findings of the luminal narrowing and velocity criteria. The study outcomes were defined as restenosis of the ipsilateral carotid artery after CEA and late (>30days) fatal or nonfatal stroke ipsilateral to the carotid restenosis. During the median follow-up period of 74 months, the restenosis incidence was 2.8% (20/717), and there were 2 strokes (2/20, 10%) ipsilateral to the restenosis after CEA; reintervention was performed for 11 patients with carotid restenosis (55%). Within 2 years after CEA, restenosis was identified in 9 cases (45%, 9/20), and 8 reinterventions (72.7%, 8/11) were performed. According to DUS findings, the morphologic characteristics of carotid restenosis were different from the preoperative plaque morphology. Among the 20 carotid restenosis cases, we observed the following DUS patterns: homogenous isoechoic restenosis (n = 14, 70%), homogenous hypoechoic (n = 2, 10%), isoechoic with hypoechoic surface (n = 3, 15%), and hypoechoic with isoechoic surface (n = 1, 5%). Although 9 carotid restenosis patients received prophylactic reintervention to mitigate the progression of restenosis, the 2 symptomatic restenosis patients had isoechoic lesions with hypoechoic surfaces on DUS. On Kaplan-Meier survival analyses, in terms of stroke-free survival rates, there was a higher risk of stroke among patients with carotid restenosis compared with patients without restenosis, with a non-significant trend (P = 0.051). In conclusion, most carotid restenoses were identified within 2 years after CEA, and there was a non-significant trend toward a higher risk of stroke among patients with carotid restenosis.

Complex redo cervical and vertebral artery reconstruction for Takayasu arteritis

A 54-year-old woman presented with an enlarging, pulsatile left neck mass and a history of Takayasu arteritis. She had seven prior cervical vascular reconstructions, including a prosthetic right-to-left carotid crossover, and left vertebral and subclavian bypasses done with saphenous vein. The skin of her neck was scarred and thin. The anastomotic pseudoaneurysms were resected, the left carotid bifurcation was reconstructed with the cryopreserved femoral artery because of the concern about wound healing, and the subclavian and vertebral vein grafts were reimplanted. Intraoperative management, clamp sites and sequence, manner of shunting, choice of conduit, and wound healing were important considerations.

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.

Effects of patient age on outcomes after carotid endarterectomy: A retrospective, single-center study in Korea

In this single-center, retrospective study, we aimed to compare early and late outcomes after carotid endarterectomy (CEA) between younger and elderly patients and to investigate the impact of patient age on the overall incidence of cardiovascular events after CEA.A total of 613 patients with 675 CEAs between January 2007 and December 2014 were stratified by patient age into 2 groups: younger (≤60 years, n = 103 CEAs, 15.3%) and elderly (>60 years, n = 572 CEAs, 84.7%) groups. The study outcomes were defined as the occurrence of major adverse events (MAEs), including fatal or nonfatal stroke or myocardial infarction (MI), or any-cause mortality, and overall cardiovascular events (meaning the composite incidence of stroke or MI) during the perioperative period and within 4 years after CEA.Although there were no significant differences in the incidence of 30-day MAEs and any of the individual MAE manifestations between the 2 groups, the differences in the MAE incidence (P = .006) and any-cause mortality (P = .023) within 4 years after CEA were significantly greater in patients in the elderly group. For overall incidence of cardiovascular events, no significant difference was noted between the 2 groups (P = .096). On multivariate analysis, older age (>60 years) did not affect the incidence of perioperative MAEs and individual MAE manifestations; however, older age was significantly associated with an increased risk of 4-year MAEs (hazard ratio [HR], 3.68, 95% confidence interval [CI], 1.35-10.0; P = .011) and any-cause mortality (HR, 3.26, 95% CI, 1.02-10.5; P = .047). With regard to the 4-year overall incidence of cardiovascular events, older age was not an independent predictor of increased risk of these cardiovascular events.Our study indicates that the risks of perioperative MAEs and the 4-year overall incidence of cardiovascular events do not significantly differ between younger and elderly Korean patients undergoing CEA, although there was a higher risk of 4-year any-cause mortality in the elderly patients. Older age does not appear to be an independent risk factor for perioperative MAEs and overall cardiovascular events within 4 years after CEA.

Risk Factors for Restenosis After Carotid Revascularization: A Meta-Analysis of Hazard Ratios

BACKGROUND

Carotid artery restenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS) will occur in 3%-30% of cases. Restenosis can lead to more frequent clinical and imaging monitoring and the potential for reoperation. We sought to define the demographic, clinical, and radiographic characteristics that influence the restenosis risk after carotid revascularization.

METHODS

The present study was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. A random effects model meta-analysis of hazard ratios (HRs) was conducted.

RESULTS

Eighteen studies with 17,106 patients were included. Diabetes (HR, 1.68; 95% confidence interval [CI], 1.00-2.83; I², 76.7%), dyslipidemia (HR, 1.77; 95% CI, 1.08-2.91; I², 22.5%), female gender (HR, 1.50; 95% CI, 1.14-1.98, I², 0%), chronic kidney disease (HR, 4.15; 95% CI, 1.69-10.19; I², 44.5%), hypertension (HR, 1.99; 95% CI, 1.07-3.72; I², 68%), smoking (HR, 1.65; 95% CI, 1.15-2.37; I², 54.3%), and pretreatment stenosis >70% (HR, 1.04; 95% CI, 1.0-1.08; I², 0%) showed a statistically significant increase in restenosis risk after carotid revascularization. Subgroup analyses of CEA and CAS showed that female gender and smoking status were significantly associated with recurrent stenosis after CEA but not after CAS. In contrast, hypertension was associated with restenosis after CAS but not after CEA. Patch endarterectomy (HR, 0.33; 95% CI, 0.22-0.50; I², 0%) and symptomatic status at presentation in the CAS group (HR, 0.61; 95% CI, 0.41-0.90; I², 0%) were associated with a decreased risk of restenosis. Antiplatelet use and coronary artery disease were not associated with restenosis risk.

CONCLUSIONS

Diabetes, dyslipidemia, female gender, renal failure, hypertension, and smoking were associated with an increased risk of restenosis, and patch endarterectomy and symptomatic status at presentation were associated with a decreased risk of carotid restenosis. Both female gender and current smoking status were only associated with recurrent stenosis after CEA, and hypertension was only associated with restenosis after CAS.

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.

Systematic and Comprehensive Comparison of Incidence of Restenosis Between Carotid Endarterectomy and Carotid Artery Stenting in Patients with Atherosclerotic Carotid Stenosis

OBJECTIVE

The purpose of the present study was to conduct a meta-analysis to systematically compare the incidence rates of in-stent restenosis after carotid artery stenting (CAS) and restenosis after carotid endarterectomy (CEA) for patients with atherosclerotic carotid stenosis.

METHODS

We retrieved potential academic reports comparing restenosis between CEA and CAS from the MEDLINE, PubMed, and EMBASE databases and the Cochrane Library from the date of the first CEA (January 1951) to July 20, 2018. The references of the identified studies were carefully reviewed to ensure that all available reports were included in the present study.

RESULTS

Our meta-analysis included 27 studies (15 randomized controlled trials, 12 nonrandomized controlled trials) and 20,479 participants with atherosclerotic carotid stenosis. A statistically significant difference was found in the cumulative incidence of restenosis >70% between CEA and CAS (risk difference, -0.033, 95% confidence interval [CI] -0.054 to -0.013; P = 0.002). For the restenosis >70% outcomes, although CEA was relevant with a lower rate of restenosis than CAS within 6 months (odds ratio [OR], 0.495; 95% CI, 0.285-0.861; P = 0.013) and 1 year (OR, 0.626; 95% CI, 0.483-0.811; P < 0.001), no statistically significant differences were found at 1.5 years (P = 0.210), 2 years (P = 0.123), 4 years (P = 0.124), 5 years (P = 0.327), or 10 years (P = 0.839). For the restenosis >50% outcomes, a significant difference was found in the rate of restenosis between the CEA and CAS groups within 1 year (OR, 0.317; 95% CI, 0.228-0.441; P < 0.001) but not at 1.5 years (P = 0.301), 2 years (P = 0.686), or 5 years (P = 0.920). No nominally significant effects were demonstrated with respect to the cumulative incidence of occlusion (P = 0.195) or the cumulative incidence of restenosis for symptomatic patients (P = 0.170) between CEA and CAS.

CONCLUSIONS

Although CAS was preferred over CEA, regardless of restenosis >50% or >70% after revascularization within 1 year, no significant difference was observed with extension of the follow-up period to >1 year. CAS was not associated with a greater cumulative incidence of occlusion or the cumulative incidence of restenosis for symptomatic patients.

Effect of Open- vs Closed-Cell Stent Design on Periprocedural Outcomes and Restenosis After Carotid Artery Stenting: A Systematic Review and Comprehensive Meta-analysis

Purpose:To compare periprocedural complications and in-stent restenosis rates associated with open- vs closed-cell stent designs used in carotid artery stenting (CAS). Methods: A systematic search was conducted to identify all randomized and observational studies published in English up to October 31, 2017, that compared open- vs closed-cell stent designs in CAS. Identified studies were included if they reported the following outcomes: stroke, transient ischemic attack (TIA), myocardial infarction (MI), hemodynamic depression, new ischemic lesions detected on imaging, and death within 30 days, as well as the incidence of in-stent restenosis. A random-effects model meta-analysis was employed. Model results are reported as the odds ratio (OR) and 95% confidence interval (CI). The I2 statistic was used to assess heterogeneity. Results: Thirty-three studies (2 randomized trials) comprising 20, 291 patients (mean age 71.3±3.0 years; 74.6% men) were included. Patients in the open-cell stent group had a statistically significant lower risk of restenosis ⩾40% (OR 0.42, 95% CI 0.19 to 0.92; I2=0%) and ⩾70% (OR 0.23, 95% CI 0.10 to 0.52; I2=0%) at a mean follow-up of 24 months. No statistically significant differences were identified for periprocedural stroke, TIA, new ischemic lesions, MI, hemodynamic depression, or death within 30 days after CAS. Sensitivity analysis of the 2 randomized controlled trials only did not point to any significant differences either. Conclusion: Use of open-cell stent design in CAS is associated with a decreased risk for restenosis when compared to the closed-cell stent, without significant differences in periprocedural outcomes.

Perioperative outcomes after reoperative carotid endarterectomy are worse than expected

OBJECTIVE

Reoperative carotid endarterectomy (CEA) can be technically challenging because of significant scarring as a consequence of the initial CEA procedure. There are limited data that describe outcomes after reoperative CEA, and as such, our goal was to determine the effect of reoperative CEA on perioperative outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients undergoing index and reoperative CEA between 2005 and 2014. Multivariate analysis was performed to assess the effect of reoperative CEA on outcomes including stroke, major adverse cardiovascular event, and procedure time.

RESULTS

There were 75,943 index and 140 reoperative CEAs identified. No differences were found in baseline demographics or comorbidities except that the reoperative group had a higher incidence of patients with end-stage renal disease (3.6% vs 1.1%; P = .004). Prior stroke with deficit (20.8% vs 15.4%; P = .137) and without deficit (11.5% vs 9.1%; P = .43) were similar between reoperative and index CEA groups. Both the reoperative and index initial CEA cohorts had comparable rates of surgical site infection (0.7% vs 0.3%; P = .462), return to the operating room (3.6% vs 4%; P = .816), readmission with 30 days (2.1% vs 6.9%; P = .810), myocardial infarction (2.1% vs 0.9%; P = .125), and perioperative death (0.7% vs 0.9%; P = .853). The reoperative cohort had a significantly higher rate of perioperative stroke (5.0% vs 1.6%; P = .002) and a longer operative duration (137 ± 54 vs 116 ± 49 minutes; P < .001). Multivariate analysis revealed that reoperative CEA was an independent factor for postoperative stroke (odds ratio, 3.71; 95% confidence interval [CI], 1.61-8.57; P = .002), major adverse cardiovascular event (odds ratio, 2.76; 95% CI, 1.32-5.78; P = .007), and longer procedure time (means ratio, 1.21; 95% CI, 1.12-1.30; P < .001).

CONCLUSIONS

Reoperative carotid surgery is associated with a longer operative time and higher risk for perioperative stroke compared with index CEA. This information informs the risk-benefit analysis for reoperation.

Impact of Hypertriglyceridemia on Carotid Stenosis Progression under Normal Low-Density Lipoprotein Cholesterol Levels

BACKGROUND

Dyslipidemia is a well-known risk factor for carotid stenosis progression, but triglycerides have attracted little attention. The aim of this study was to assess if serum triglycerides affect progression of carotid stenosis in patients with well-controlled low-density lipoprotein cholesterol (LDL-C) levels.

METHODS

This is a retrospective study in a single hospital consisting of 71 Japanese patients with internal carotid artery stenosis greater than or equal to 50% and normal serum LDL-C levels who underwent angiographic examination with or without the resultant carotid artery stenting or endarterectomy from 2007 to 2011, and were subsequently followed up for 4 years. Clinical factors including fasting serum triglyceride values were compared between the progression (≥10% increase in degree of carotid stenosis on ultrasonography) and the nonprogression groups.

RESULTS

During 4 years, 15 patients (21.1%) had carotid stenosis progression on either side. Cox regression analysis demonstrated that symptomatic cases (hazard ratio [HR], 4.327; P = .019), coexisting intracranial arteriosclerotic stenosis (HR, 5.341; P = .005), and hypertriglyceridemia (HR, 6.228; P = .011) were associated with subsequent progression of carotid stenosis. Kaplan-Meier plots demonstrated that the progression-free survival rate was significantly higher in patients without hypertriglyceridemia and intracranial arteriosclerotic stenosis at baseline.

CONCLUSIONS

Among patients with moderate to severe carotid stenosis and well-controlled LDL-C, hypertriglyceridemia was an important risk factor for progression of carotid stenosis irrespective of surgical treatments. It would be worthwhile to test if triglyceride-lowering medications suppress carotid stenosis progression.

Prosthetic bypass for restenosis after endarterectomy or stenting of the carotid artery

OBJECTIVE

The objective of this study was to evaluate the results of prosthetic carotid bypass (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to carotid endarterectomy (CEA) in treatment of restenosis after CEA or carotid artery stenting (CAS).

METHODS

From January 2000 to December 2014, 66 patients (57 men and 9 women; mean age, 71 years) presenting with recurrent carotid artery stenosis ≥70% (North American Symptomatic Carotid Endarterectomy Trial [NASCET] criteria) were enrolled in a prospective study in three centers. The study was approved by an Institutional Review Board. Informed consent was obtained from all patients. During the same period, a total of 4321 CEAs were completed in the three centers. In these 66 patients, the primary treatment of the initial carotid artery stenosis was CEA in 57 patients (86%) and CAS in nine patients (14%). The median delay between primary and redo revascularization was 32 months. Carotid restenosis was symptomatic in 38 patients (58%) with transient ischemic attack (n = 20) or stroke (n = 18). In this series, all patients received statins; 28 patients (42%) received dual antiplatelet therapy, and 38 patients (58%) received single antiplatelet therapy. All PCBs were performed under general anesthesia. No shunt was used in this series. Nasal intubation to improve distal control of the internal carotid artery was performed in 33 patients (50%), including those with intrastent restenosis. A PTFE graft of 6 or 7 mm in diameter was used in 6 and 60 patients, respectively. Distal anastomosis was end to end in 22 patients and end to side with a clip distal to the atherosclerotic lesions in 44 patients. Completion angiography was performed in all cases. The patients were discharged under statin and antiplatelet treatment. After discharge, all of the patients underwent clinical and Doppler ultrasound follow-up every 6 months. Median length of follow-up was 5 years.

RESULTS

No patient died, sustained a stroke, or presented with a cervical hematoma during the postoperative period. One transient facial nerve palsy and two transient recurrent nerve palsies occurred. Two late strokes in relation to two PCB occlusions occurred at 2 years and 4 years; no other graft stenosis or infection was observed. At 5 years, overall actuarial survival was 81% ± 7%, and the actuarial stroke-free rate was 93% ± 2%. There were no fatal strokes.

CONCLUSIONS

PCB with PTFE grafts is a safe and durable alternative to CEA in patients with carotid restenosis after CEA or CAS in situations in which CEA is deemed either hazardous or inadvisable.

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

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.

Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal

OBJECTIVE

This report presents the 30-day results of the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial and evaluates the safety and efficacy of ENROUTE Transcarotid NPS (Silk Road Medical Inc, Sunnyvale, Calif), a novel transcarotid neuroprotection system that provides direct surgical common carotid access and cerebral embolic protection via high-rate flow reversal during carotid artery stenting (CAS).

METHODS

A prospective, single-arm, multicenter clinical trial was performed to evaluate the use of the ENROUTE Transcarotid NPS during CAS procedures performed in patients considered to be at high risk for complications from carotid endarterectomy. Symptomatic patients with ≥50% stenosis and asymptomatic patients with ≥70% stenosis were eligible to be treated with any U.S. Food and Drug Administration-approved carotid artery stent. The primary end point was the composite of all stroke, myocardial infarction (MI), and death at 30 days postprocedure as defined in the Food and Drug Administration-approved study protocol. Secondary end points included cranial nerve injury; 30-day stroke, death, stroke/death, and MI; acute device, technical, and procedural success; and access site complications. All major adverse events were adjudicated by an independent clinical events committee.

RESULTS

Between November 2012 and July 2014, 208 patients were enrolled at 18 sites. Sixty-seven patients were enrolled as lead-in cases, and 141 were enrolled in the pivotal phase. In the pivotal cohort, 26% were symptomatic and 75% were asymptomatic. Acute device and technical success were 99% (140 of 141). By hierarchical analysis, the all-stroke rate in the pivotal group was 1.4% (2 of 141), stroke and death was 2.8% (4 of 141), and stroke, death and MI was 3.5% (5 of 141). One patient (0.7%) experienced postoperative hoarseness from potential Xth cranial nerve injury, which completely resolved at the 6-month follow-up visit.

CONCLUSIONS

The results of the ROADSTER trial demonstrate that the use of the ENROUTE Transcarotid NPS is safe and effective at preventing stroke during CAS. The overall stroke rate of 1.4% is the lowest reported to date for any prospective, multicenter clinical trial of CAS.

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.

Long-term Comparative Outcomes of Carotid Artery Stenting Following Previous Carotid Endarterectomy vs De Novo Lesions

PURPOSE

To report the long-term outcomes of patients who underwent carotid artery stenting (CAS) for de novo carotid stenosis vs patients treated for restenosis after carotid endarterectomy (CEA).

METHODS

A retrospective review was conducted of all 385 patients (mean age 68.6±9.6 years; 231 men) who underwent 435 CAS procedures at a large tertiary care center between January 1999 and December 2013. For analysis, patients were stratified based on their lesion type [de novo (dn) vs post-CEA restenosis (res)] and subclassified by symptoms status [symptomatic (Sx) or asymptomatic (Asx)], creating 4 groups: (1) CAS-dn Asx, (2) CAS-dn Sx, (3) CAS-res Asx, and (4) CAS-res Sx. For the CAS-res group, the mean elapsed time from CEA to CAS was 72.4±63.6 months. Outcomes included target vessel reintervention (TVR) and in-stent restenosis (ISR), the latter defined by a carotid duplex ultrasound velocity >275 cm/s.

RESULTS

The main indication for initial carotid angiography with possible revascularization was severe carotid stenosis (≥70%-99% on duplex) in both CAS-dn and CAS-res groups (83.6% vs 83.7%, p=0.999). There were no significant differences in the percentage of patients with postintervention residual stenosis (<30%; 100% each arm) or complications between CAS-res vs CAS-dn: in-hospital stroke (1.4% vs 1.8%, respectively), myocardial infarction (0.9% vs 0%), or death (0.9% vs 0%). Mean follow-up was 62.4±45.6 months (median 53.5, range 1-180). Average clinical/TVR follow-up was greater for the CAS-res group (71.9±48.6 months) compared with 53.3±40.5 months for the CAS-dn group (p<0.001). Across the 4 study groups, there were no differences in freedom from ISR (p=0.174) or TVR (p=0.856). Multivariate analysis found peripheral vascular disease (PVD) as the sole ISR independent predictor [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.03 to 3.62, p=0.041], while significant predictors for TVR were age <65 years at the time of the procedure (HR 2.55, 95% CI 1.05 to 6.18, p=0.039) and PVD (HR 2.46, 95% CI 1.03 to 5.87, p=0.043).

CONCLUSION

The current study suggests that CAS is a feasible and durable therapeutic option for recurrent restenosis after CEA. Long-term outcomes were similar for patients treated for de novo lesions or post-CEA restenosis. Age and PVD appear to influence long-term CAS durability.

Stenting versus endarterectomy for restenosis following prior ipsilateral carotid endarterectomy: an individual patient data meta-analysis

OBJECTIVE

To study perioperative results and restenosis during follow-up of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for restenosis after prior ipsilateral CEA in an individual patient data (IPD) meta-analysis.

BACKGROUND

The optimal treatment strategy for patients with restenosis after CEA remains unknown.

METHODS

A comprehensive search of electronic databases (Medline, Embase) until July 1, 2013, was performed, supplemented by a review of references. Studies were considered for inclusion if they reported procedural outcome of CAS or CEA after prior ipsilateral CEA of a minimum of 5 patients. IPD were combined into 1 data set and an IPD meta-analysis was performed. The primary endpoint was perioperative stroke or death and the secondary endpoint was restenosis greater than 50% during follow-up, comparing CAS and CEA.

RESULTS

In total, 13 studies were included, contributing to 1132 unique patients treated by CAS (10 studies, n = 653) or CEA (7 studies; n = 479). Among CAS and CEA patients, 30% versus 40% were symptomatic, respectively (P < 0.01). After adjusting for potential confounders, the primary endpoint did not differ between CAS and CEA groups (2.3% vs 2.7%, adjusted odds ratio 0.8, 95% confidence interval (CI): 0.4-1.8). Also, the risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio 1.4, 95% (CI): 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was in 5% associated with other procedural related complications.

CONCLUSIONS

In patients with restenosis after CEA, CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up. Still, the risk of CNI and other procedure-related complications should be taken into account.

Drug-coated balloon dilation before carotid artery stenting of post-carotid endarterectomy restenosis

PURPOSE

To investigate if drug-coated balloon (DCB) predilation may improve the efficacy of carotid artery stenting (CAS) for restenosis after carotid endarterectomy (CEA).

METHODS

Eighteen consecutive patients (11 men; median age 75 years) with significant restenosis within 24 months of CEA were treated with a paclitaxel-coated DCB prior to CAS. Clinical outcomes and stent patency were systematically appraised.

RESULTS

All patients were successfully treated according to this clinical protocol. The only complication occurred in a patient who had a transient ischemic attack during prolonged DCB inflation. At a median follow-up of 18 months, no >50% restenosis was observed on duplex ultrasound scans; however, moderate hyperplasia at the proximal stent edge was found in 4 patients. One patient died at 9 months from a myocardial infarction.

CONCLUSION

Despite the small sample size and in keeping with the historically high risk of recurrent restenosis after CAS for CEA restenosis, this case series suggests that DCB dilation followed by CAS for postsurgical restenosis is feasible, safe, and may be associated with favorable clinical outcomes at midterm follow-up.

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.

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.

Crosstalk between TGF-β/Smad3 and BMP/BMPR2 signaling pathways via miR-17-92 cluster in carotid artery restenosis

In the recent decades, carotid angioplasty and stenting (CAS) has been developed into a credible option for the patients with carotid stenosis. However, restenosis remains a severe and unsolved issue after CAS treatment. Restenosis is characterized by neointimal hyperplasia, which is partially caused by vascular smooth muscle cells (VSMC) proliferation. However, the molecular mechanism involved in the restenosis is still unclear. In this study, we demonstrated a functional crosstalk between two TGF-β superfamily signaling pathway members, Smad3 and BMPR2, in VSMC proliferation. Smad3 plays an important role in the TGF-β/Smad3 signaling pathway, and is significantly upregulated in the carotid artery with restenosis to promote VSMC proliferation. In contrast, BMP receptor II (BMPR2), an inhibitor of VSMC proliferation is downregulated in carotid restenosis. We further found that BMPR2 downregulation is mediated by miR-17-92 cluster, which is transcriptionally regulated by Smad3. Thus, Smad3 upregulation and Smad3/miR-17-92 cluster-dependent BMPR2 downregulation are likely to promote VSMC proliferation and restenosis. Taken together, our results may provide novel clues for early diagnosis of carotid restenosis and developing new therapeutic strategy.

Clinical relevance of cranial nerve injury following carotid endarterectomy

OBJECTIVES

The benefit of carotid endarterectomy (CEA) may be diminished by cranial nerve injury (CNI). Using a quality improvement registry, we aimed to identify the nerves affected, duration of symptoms (transient vs. persistent), and clinical predictors of CNI.

METHODS

We identified all patients undergoing CEA in the Vascular Study Group of New England (VSGNE) between 2003 and 2011. Surgeon-observed CNI rate was determined at discharge (postoperative CNI) and at follow-up to determine persistent CNI (CNIs that persisted at routine follow-up visit). Hierarchical multivariable model controlling for surgeon and hospital was used to assess independent predictors for postoperative CNI.

RESULTS

A total of 6,878 patients (33.8% symptomatic) were included for analyses. CNI rate at discharge was 5.6% (n = 382). Sixty patients (0.7%) had more than one nerve affected. The hypoglossal nerve was most frequently involved (n = 185, 2.7%), followed by the facial (n = 128, 1.9%), the vagus (n = 49, 0.7%), and the glossopharyngeal (n = 33, 0.5%) nerve. The vast majority of these CNIs were transient; only 47 patients (0.7%) had a persistent CNI at their follow-up visit (median 10.0 months, range 0.3-15.6 months). Patients with perioperative stroke (0.9%, n = 64) had significantly higher risk of CNI (n = 15, CNI risk 23.4%, p < .01). Predictors for CNI were urgent procedures (OR 1.6, 95% CI 1.2-2.1, p < .01), immediate re-exploration after closure under the same anesthetic (OR 2.0, 95% CI 1.3-3.0, p < .01), and return to the operating room for a neurologic event or bleeding (OR 2.3, 95% CI 1.4-3.8, p < .01), but not redo CEA (OR 1.0, 95% CI 0.5-1.9, p = .90) or prior cervical radiation (OR 0.9, 95% CI 0.3-2.5, p = .80).

CONCLUSIONS

As patients are currently selected in the VSGNE, persistent CNI after CEA is rare. While conditions of urgency and (sub)acute reintervention carried increased risk for postoperative CNI, a history of prior ipsilateral CEA or cervical radiation was not associated with increased CNI rate.

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.