Carotid endarterectomy for treatment of carotid in-stent restenosis: long-term follow-up results and surgery experiences from one single centre

Alterations in metabolome and lipidome in patients with in-stent restenosis

CONTEXT

In-stent restenosis (ISR) can lead to blood flow obstruction, insufficient blood supply to the brain, and may even result in serious complications such as stroke. Endothelial cell hyperproliferation and thrombosis are the primary etiologies, frequently resulting in alterations in intravascular metabolism. However, the metabolic changes related to this process are still undermined.

OBJECTIVE

We tried to characterize the serum metabolome of patients with ISR and those with non-restenosis (NR) using metabolomics and lipidomics, exploring the key metabolic pathways of this pathological phenomenon.

RESULTS

We observed that the cysteine and methionine pathways, which are associated with cell growth and oxidative homeostasis, showed the greatest increase in the ISR group compared to the NR group. Within this pathway, the levels of N-formyl-l-methionine and L-methionine significantly increased in the ISR group, along with elevated levels of downstream metabolites such as 2-ketobutyric acid, pyruvate, and taurocholate. Additionally, an increase in phosphatidylcholine (PC) and phosphatidylserine (PS), as well as a decrease in triacylglycerol in the ISR group, indicated active lipid metabolism in these patients, which could be a significant factor contributing to the recurrence of blood clots after stent placement. Importantly, phenol sulfate and PS(38:4) were identified as potential biomarkers for distinguishing ISR, with an area under the curve of more than 0.85.

CONCLUSIONS

Our study revealed significant metabolic alterations in patients with ISR, particularly in the cysteine and methionine pathways, with phenol sulfate and PS(38:4) showing promise for ISR identification.

Feasibility and efficiency of a new classification based on high-resolution MRI for carotid artery pseudo-occlusion and occlusion: Hybrid revascularization pilot study

BACKGROUND AND PURPOSE

Studies on changes in the distal internal carotid artery based on high resolution magnetic resonance imaging (HRMRI) are scarce. Herein, we propose a histological classification system for patients with carotid artery pseudo-occlusion or occlusion based on preoperative HRMRI, for which we evaluated the feasibility and clinical implications.

MATERIALS AND METHODS

From January 2017 to June 2021, 40 patients with Doppler ultrasound, CTA or MRA suggesting carotid artery occlusion were enrolled in this study. A new classification system based on HRMRI was established and subsequently verified by postoperative specimens. We recorded and analyzed patient characteristics, HRMRI data, recanalization rate, requirements of additional endovascular procedures, complications, and outcomes.

RESULTS

Four histological classifications (type Ⅰ-Ⅳ) were identified. According to our classification system, 20 patients (50.00%) were type I, nine (22.50%) were type II, 7 (17.50%) were type III, and four (10.00%) were type Ⅳ. The success rate of recanalization was 88.89% (32/36) in type I-III patients. Four (44.44%) type Ⅱ patients and five (71.43%) type Ⅲ patients suffered from intraoperative dissection.

CONCLUSION

Patients identified as types I (pseudo-occlusion) and II (thrombotic-occlusion) were able to be treated via hybrid revascularization with relatively low risk, while patients identified as type III (fibrous-occlusion) required more careful treatment. Recanalization is not suitable for patients identified as type Ⅳ. Our proposed classification system based on HRMRI data can be used as an adjunctive guide to predict the technical feasibility and success of revascularization via a hybrid technique.

Comparison of carotid endarterectomy and repeated carotid angioplasty and stenting for in-stent restenosis (CERCAS trial): a randomised study

BACKGROUND AND AIM

In-stent restenosis (ISR) belongs to an infrequent but potentially serious complication after carotid angioplasty and stenting in patients with severe carotid stenosis. Some of these patients might be contraindicated to repeat percutaneous transluminal angioplasty with or without stenting (rePTA/S). The purpose of the study is to compare the safety and effectiveness of carotid endarterectomy with stent removal (CEASR) and rePTA/S in patients with carotid ISR.

METHODS

Consecutive patients with carotid ISR (≥80%) were randomly allocated to the CEASR or rePTA/S group. The incidence of restenosis after intervention, stroke, transient ischaemic attack myocardial infarction and death 30 days and 1 year after intervention and restenosis 1 year after intervention between patients in CEASR and rePTA/S groups were statistically evaluated.

RESULTS

A total of 31 patients were included in the study; 14 patients (9 males; mean age 66.3±6.6 years) were allocated to CEASR and 17 patients (10 males; mean age 68.8±5.6 years) to the rePTA/S group. The implanted stent in carotid restenosis was successfully removed in all patients in the CEASR group. No clinical vascular event was recorded periproceduraly, 30 days and 1 year after intervention in both groups. Only one patient in the CEASR group had asymptomatic occlusion of the intervened carotid artery within 30 days and one patient died in the rePTA/S group within 1 year after intervention. Restenosis after intervention was significantly greater in the rePTA/S group (mean 20.9%) than in the CEASR group (mean 0%, p=0.04), but all stenoses were <50%. Incidence of 1-year restenosis that was ≥70% did not differ between the rePTA/S and CEASR groups (4 vs 1 patient; p=0.233).

CONCLUSION

CEASR seems to be effective and save procedures for patients with carotid ISR and might be considered as a treatment option.

TRIAL REGISTRATION NUMBER

NCT05390983.

Spotlight on clinical strategies of Chronic Internal Carotid Artery Occlusion: Endovascular interventions and external-intracarotid bypasses compared to conservative treatment

Chronic internal carotid artery occlusion (CICAO) has high prevalence and incidence rates, and patients with CICAO can be completely asymptomatic, experience a devastating stroke or die. It is important to note that CICAO causes cerebrovascular accidents. Currently, the external carotid-internal carotid (EC-IC) bypass technique is used to treat CICAO. However, many clinical studies showed that EC-IC bypass was not beneficial for many patients with CICAO. Meanwhile, endovascular intervention treatment options for CICAO are evolving, and an increasing number of patients are undergoing endovascular intervention therapy. Accordingly, a review comparing both techniques is warranted. For this review, we searched PubMed and collected relevant case study reports comparing endovascular interventional therapy and internal and external cervical bypass surgeries to provide strategies for clinical treatment.

Carotid endarterectomy with stent removal for recurring in-stent restenosis: A case report and literature review

Background:

Percutaneous transcatheter angioplasty (PTA) and carotid artery stenting (CAS) are often performed repeatedly for in-stent restenosis (ISR) after CAS. Only a few reports describe the treatment for repeated ISR. Furthermore, only a few reports describe carotid endarterectomy (CEA) after CAS; thus, the evidence for this procedure is insufficient.

Case Description:

Herein, we describe a case in which CEA with stent removal was performed in a patient with repeated ISR after CAS. A 78-year-old man presented with dysarthria and slight left limb weakness. CAS was performed for the right internal carotid artery stenosis. ISR occurred again and PTA and stenting were performed. After the second CAS, ISR occurred again. CEA with stent removal was performed. After the CEA with stent removal, the patient experienced no restenosis or other complications.

Conclusion:

CEA with stent removal can be a good option for treating repeated ISR after CAS.

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.

Carotid Endarterectomy with Stent Graft Removal and End to End Bypass in the Treatment of In-Stent Occlusion after Endovascular Therapy of Carotid Gunshot Injury

Carotid jugular fistula and pseudoaneurysm are easy to form after gunshot injury of carotid artery. Endovascular therapy, such as stent graft implantation, can successfully block the fistula and pseudoaneurysm cavity. However, the possibility of in-stent restenosis or occlusion will lead to treatment failure. The authors describe the case of a 30-year-old man with carotid jugular fistula and pseudoaneurysm after gunshot injury of left carotid artery who had received stent graft placement. However, two years after stent graft, the stenosis of proximal carotid artery near stent was found and gradually aggravated. During the follow-up, transient amaurosis of his left eye occurred intermittently and in-stent occlusion and severe stenosis of proximal carotid artery were found by computed tomography angiography (CTA) in our center. Carotid endarterectomy (CEA)with stent graft removal and end to end bypass using vascular graft was performed to reconstruct the blood flow of left carotid artery. To the extent of the authors' knowledge, this case illustrates a rare CEA and vascular graft bypass in the treatment of in-stent occlusion following the gunshot injury to the carotid artery. The successful treatment of this rare case provides an option to deal with this kind of tricky problem.

[Carotid endarterectomy in a patient with bilateral restenosis of stents in internal carotid arteries]

The article deals with the results of surgical treatment of a male patient presenting with bilateral restenosis of stents in the internal carotid arteries 11 years after carotid angioplasty with stenting. Described herein are literature reports reflecting the state of the art of the problem, scarcity of studies, as well as some important issues still unresolved. Defined are the main indications for and contraindications to performing this type of reconstruction. The main stages of the operation are demonstrated. This is followed by describing a method of intraoperative protection of the brain, including invasive measurement of retrograde pressure. Besides, the most optimal terms of carrying out the second stage of treatment were determined, eventually demonstrating efficacy and safety of carotid endarterectomy for correction of this condition.

Hybrid Recanalization for the Treatment of Carotid/Vertebral In-stent Restenosis or Occlusion: Pilot Surgery Experiences From One Single Center

Background : The hybrid recanalization of internal carotid artery (ICA) and vertebral artery (VA) in-stent restenosis or occlusion using a combination of endarterectomy and endovascular intervention has achieved technical success. We present our surgical experiences to further evaluate the safety and efficacy of the hybrid technique for the treatment of in-stent restenosis and occlusion. Methods : A cohort of 12 refractory patients with in-stent restenosis or occlusion who underwent hybrid recanalization, a combination of endarterectomy and endovascular intervention, were retrospectively analyzed. Medical records, including presenting symptoms, comorbidities, contralateral ICA/VA findings, use of antiplatelet drugs, postoperative complications, and angiographic outcomes, were collected. Results : Among 415 consecutive patients with ICA, common carotid artery, and V1 segment lesions, 12 refractory patients (2.89%) with 13 cases were enrolled in our study (1 female and 11 male). All patients underwent successful hybrid recanalization. There were no cases of postoperative stroke or death. Only two patients sustained hoarseness, but it resolved within 2 weeks after surgery. Three patients were treated with dual antiplatelet (aspirin and clopidogrel), seven with single antiplatelet (aspirin), one with single antiplatelet (clopidogrel), and one with single antiplatelet (ticagrelor). All patients were followed up in the outpatient department according to the protocol, with a mean follow-up period of 13 months (range, 6-24 months). No death or recurrent symptoms occurred during the regular follow-up period. Conclusion : The hybrid technique maybe a safe and feasible treatment option to recanalize in-stent restenosis or occlusion with acceptable complications.

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 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.