Zotarolimus-eluting stent for the treatment of recurrent, severe carotid artery in-stent stenosis in the TARGET-CAS population

Prevention of in-stent restenosis with drug-eluting balloons in patients with postirradiated carotid stenosis accepting percutaneous angioplasty and stenting

OBJECTIVE

To investigate the technical safety and outcome of in-stent restenosis (ISR) prevention with drug-eluting balloon (DEB) in patients with postirradiated carotid stenosis (PIRCS) undergoing percutaneous angioplasty and stenting (PTAS).

METHODS

Between 2017 and 2021, we prospectively recruited patients with severe PIRCS for PTAS. They were randomly separated into two groups based on endovascular techniques performed with and without DEB. Preprocedural and early postprocedural (within 24 hours) MRI, short-term ultrasonography (6 months after PTAS), and long-term CT angiography (CTA)/MR angiography (MRA), 12 months after PTAS, were performed. Technical safety was evaluated based on periprocedural neurological complications and the number of recent embolic ischemic lesions (REIL) in the treated brain territory on diffusion-weighted imaging of early postprocedural MRI.

RESULTS

Sixty-six (30 with and 36 without DEB) subjects were enrolled, with one failure in techniques. For 65 patients in the DEB versus conventional groups, technical neurological symptoms within 1 month (1/29 (3.4%) vs 0/36; P=0.197) and REIL numbers within 24 hours (1.0±2.1 vs 1.3±1.5; P=0.592) after PTAS showed no differences. Peak systolic velocity (PSVs) on short-term ultrasonography was significantly higher in the conventional group (104.13±42.76 vs .81.95±31.35; P=0.023). The degree of in-stent stenosis (45.93±20.86 vs 26.58±8.75; P<0.001) was higher, and there were more subjects (n=8, 38.9% vs 1, 3.4%; P=0.029) with significant ISR (≥ 50%) in the conventional group than in the DEB group on long-term CTA/MRA.

CONCLUSIONS

We observed similar technical safety of carotid PTAS with and without DEBs. The number of cases of significant ISR were fewer and the degree of stenosis of ISR was less in primary DEB-PTAS of PIRCS than for conventional PTAS in the 12-month follow-up.

Diabetes Mellitus and Clinical Outcomes in Carotid Artery Revascularization Using Second-Generation, MicroNet-Covered Stents: Analysis from the PARADIGM Study

INTRODUCTION

Carotid artery stenting (CAS) using conventional (single-layer) stents is associated with worse clinical outcomes in diabetes mellitus (DM) vs. non-DM patients: an effect driven largely by lesion-related adverse events. CAS outcomes with MicroNet-covered stents (MCS) in diabetic patients have not been evaluated.

AIM

To compare short- and long-term clinical outcomes and restenosis rate in DM vs. non-DM patients with carotid stenosis treated using MCS.

MATERIALS AND METHODS

In a prospective study in all-comer symptomatic and increased-stroke-risk asymptomatic carotid stenosis, 101 consecutive patients (age 51-86 years, 41% diabetics) underwent 106 MCS-CAS. Clinical outcomes and duplex ultrasound velocities were assessed periprocedurally and at 30 days/12 months.

RESULTS

Baseline characteristics of DM vs. non-DM patients were similar except for a higher prevalence of recent cerebral symptoms in DM. Type 1 and type 1+2 plaques were more prevalent in DM patients (26.7% vs. 9.8%, p = 0.02; 62.2% vs. 37.7%, p = 0.01). Proximal embolic protection was more prevalent in DM (60% vs. 36%; p = 0.015). 30-day clinical complications were limited to a single periprocedural minor stroke in DM (2.4% vs. 0%, p = 0.22). 12-month in-stent velocities and clinical outcomes were not different (death rate 4.8% vs. 3.3%; p = 0.69; no new strokes). Restenosis rate was not different (0% vs. 1.7%, p = 0.22).

CONCLUSIONS

MCS may offset the adverse impact of DM on periprocedural, 30-day, and 12-month clinical complications of CAS and minimize the risk of in-stent restenosis. In this increased-stroke-risk cohort, adverse event rate was low both in DM and non-DM. Further larger-scale clinical datasets including extended follow-ups are warranted.

Symptomatic atherosclerotic plaque progression in a first-generation carotid stent: management and 5-year clinical and imaging outcome-a case report

Background

Restenosis in first-generation (single-layer) carotid stents (FGS) is believed to represent an exaggerated healing response of (neo)intimal hyperplasia (NIH) formation. Rather than NIH, we describe symptomatic in-FGS unstable plaque (neo)atherosclerosis mandating re-revascularization. To halt continued plaque evolution, we propose a novel treatment strategy involving a microNet-covered stent (MCS, second-generation carotid stent) to sequestrate the plaque from the vessel lumen. A durable long-term result is documented using multi-modal imaging.

Case summary

With a seemingly optimal result of FGS (Precise) symptomatic carotid lesion revascularization followed by optimal medical therapy, a late (≥3 years) progressive in-stent restenosis (ISR) arose. At Year 11, crescendo ipsilateral transient ischaemic attacks occurred. Angiography showed an ulcerated tight lesion throughout stent length. Intravascular ultrasound (IVUS) virtual histology imaging revealed thin-cap fibroatheroma. Reintervention was performed under distal protection. Undersized balloon predilatation to insert a stent caused symptomatic no-flow, and aspiration catheter was used to reduce the filter load. A MCS (CGuard) was implanted and post-dilated to ensure full lumen gain; IVUS confirmed complete plaque sequestration. The optimal anatomic result remained unchanged throughout 5 years (ultrasound and computed tomography verification); this was accompanied by clinical cure.

Discussion

This is the first demonstration of in-FGS (neo)atherosclerosis resolution using an MCS to sequestrate and insulate the atherosclerotic plaque. We show that ISR may be underlined by atherosclerotic plaque progression via the FGS single-layer stent struts that may show vulnerable plaque phenotype and may be associated with cerebral ischaemia. The anatomically and clinically effective exclusion of the atherosclerotic plaque by an MCS enabled lasting, optimal endovascular reconstruction and clinical cure.

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.

Estimated Glomerular Filtration Rate as a Predictor of Restenosis After Carotid Stenting Using First-Generation Stents

This study evaluated the impact of the baseline estimated glomerular filtration rate (eGFR) on clinical and angiographic outcomes and long-term in-stent restenosis (ISR) rates in patients undergoing elective carotid artery stenting (CAS) procedures. Consecutive patients who underwent CAS were retrospectively enrolled (n = 456). At the end of 3 years of follow-up, patients who had died or were lost follow-up were excluded from the study and a final analysis was performed using data from the remaining 405 patients. The study population (n = 405) was divided into 3 tertiles based on the tertile values of the eGFR level (T1, T2, and T3); then, clinical and procedural characteristics and 3-year ISR rates were compared between the groups. An ISR of 50% was detected in 49 (12%) surviving patients. The 3-year ISR was higher among patients with the lowest eGFR values (T1) by 3.7 times (95% CI: 2.01-11.38) than that among patients with the highest eGFR values (T3). These significant relationships persisted following adjustment for confounders. A lower baseline eGFR level was significantly associated with an increased ISR rate. Decreased renal function may be a predictor of ISR after CAS using first-generation stents.

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.

Long-term outcomes and determinants of stenosis recurrence after renal artery angioplasty in hypertensive patients with renovascular disease

INTRODUCTION

Restenosis (RS) following percutaneous angioplasty (PTA) of renal artery stenosis (RAS) might have an unfavourable impact on renal function and blood pressure (BP) outcomes.

AIM

To evaluate the prevalence and predictors of RS in patients treated with PTA for RAS, and the relationship between BP and renal function (RF) changes with RS.

MATERIAL AND METHODS

We analysed freedom from RS in 210 patients (age 64.6 ±12.8 years; range: 20-85), who underwent 248 successful stent-assisted PTAs in RAS. The change in levels of serum creatinine (SCC), estimated glomerular filtration rate (eGFR), systolic/diastolic BPs (SBP/DBP) were analysed prior to PTA, at 6-, 12-month, and final follow-up visits, and whenever RS was diagnosed.

RESULTS

RS was identified in 30 (14.3%) patients, and there were 36 (14.5%) lesions. The Kaplan-Meier RS-free survival curves in fibromuscular dysplasia, atherosclerosis, and vasculitis at 1 and 7 years were: 100% and 100%; 95.6 and 83.9%; and 71.4 and 39.7%, respectively. Patients with RS, as compared to RS-free patients, presented with less pronounced changes in respect with: SBP (1.4 ±17.6 vs. -15.8 ±25.8 mm Hg; p = 0.01), DBP (2.64 ±10.1 vs. -6.5 ±14.1 mm Hg; p = 0.002), SCC (22.4 ±55.2 vs. -3.6 ±43.9 µmol/l; p = 0.002), and eGFR (-1.85 ±18 vs. -5.34 ±19.5 mm Hg; p = 0.045). In multivariate Cox regression analysis, independent predictors of RS occurred: lack of BP decrease (HR = 4.19, 95% CI: 1.67-10.3; p = 0.002), eGFR increase < 0.17 ml/min/1.73 m2 (HR = 2.93, 95% CI: 1.08-7.91; p = 0.033), stent diameter ≤ 5 mm (HR = 2.76, 95% CI: 1.09-6.97; p = 0.031), and vasculitis (HR = 5.61, 95% CI: 1.83-17.2; p = 0.003). RS was treated in 24 patients with RS recurrence in 20%.

CONCLUSIONS

The RS rate differs depending on RAS aetiology. Lack of SBP/DBP and eGFR improvement, vasculitis, and stent diameter are associated with RS risk. Repeated PTA is effective, but recurrent RS occurs in 20% of cases.

Severe, recurrent in-stent carotid restenosis: endovascular approach, risk factors. Results from a prospective academic registry of 2637 consecutive carotid artery stenting procedures (TARGET-CAS)

Introduction

Optimal management of severe carotid in-stent restenosis remains unknown. Prevalence and risk factors of first and recurrent carotid in-stent restenosis in the multi-stent approach have not been established yet.

Aim

To evaluate the safety of different methods of endovascular treatment of carotid in-stent restenosis/recurrent restenosis and to establish its rate and risk factors.

Material and methods

Between January 2001 and June 2016, 2637 neuroprotected carotid artery stenting (CAS) procedures were performed in 2443 patients (men: 67.0%; mean age: 67.9 ±8.8 years, symptomatic: 45.5%). Doppler ultrasound (DUS) evaluation was performed at discharge, after 3-6 months, 12 months, and then annually. Peak systolic velocity of 2-3 and > 3.0 m/s as well as end diastolic velocity of 0.5-0.9 and > 0.9 m/s were DUS criteria for 50-69% and ≥ 70% carotid in-stent restenosis (ISR) respectively. For angiographically confirmed ≥ 70% stenosis balloon re-angioplasty was first line treatment.

Results

Out of 95 DUS detected > 50% ISR (95/2637; 3.6%), 53 were confirmed in angiography as ≥ 70% (53/2637; 2.0%, one total occlusion). All patients were treated with bare balloon (n = 19), drug-eluting balloon (n = 27) or stent-supported (n = 6) angioplasty. One procedure was complicated with stroke (1.9%). Angiographic diameter stenosis (DS) was reduced from 83 ±8.3% to 13 ±7.6% (p < 0.001). There were 13 cases of ≥ 70% recurrent ISR. Bilateral and high-grade stenosis were independent risk factors of restenosis. Initial Carotid Wallstent implantation was a risk factor of first and recurrent in-stent restenosis.

Conclusions

Endovascular treatment of carotid in-stent restenosis is safe. Bilateral and high-grade carotid artery stenosis may increase the risk of restenosis. Initial Carotid Wallstent implantation may increase the risk of first and recurrent restenosis.

Comparison of drug-eluting and bare metal stents for extracranial vertebral artery stenting

Introduction

Drug-eluting stents of the first (DES I) and second generation (DES II) proved superior to bare metal stents (BMS) in the coronary territory. However, there are limited data on whether they have any advantage over BMS in vertebral artery stenosis (VAS).

Aim

To compare outcomes of DES (DES I, DES II) and BMS in the treatment of symptomatic extracranial VAS.

Material and methods

During 13-year study period (2003–2016), 392 consecutive patients underwent VAS angioplasty in 428 arteries, including implantation of 148 DES (DES I: 21; DES II: 127 lesions), and 280 BMS.

Results

The technical success rates for DES and BMS groups were 96.7% and 94.6% (p = 0.103), with similar periprocedural complication rates (1.4% vs. 2.2%; p = 0.565). VAS degree was reduced from 86 ±9.7 to 2.7 ±5.0% in DES (p < 0.001) and from 84.1 ±9.4 to 4.3 ±6.9% in BMS (p < 0.001). Angiography confirmed in-stent restenosis/occlusion (ISR/ISO) 50–99% in 53 (14.2%) and 21 (5.6%) out of 373 patients (409 arteries) with at least 6-month follow-up. ISR/ISO rates were similar in DES vs. BMS (22.8% vs. 19.4%; p = 0.635), as well as in DES I vs. DES II (6/19; 31.6% vs. 25/92; 27.2%, p = 0.325). Stainless steel (24/135; 17.8%) and cobalt-chromium (23/121;19%) BMS had significantly lower incidence of ISR/ISO, as compared to platinum-chromium (7/18; 38.9%), p = 0.034. ISR/ISO was associated with age (p = 0.01) and CRP level > 5 mg/l (p = 0.043), while greater stent length was associated with ISR only in the DES group (p = 0.024).

Conclusions

Our results do not support significant differences in ISR/ISO rates between DES and BMS, although differences between particular stent types and ISR rates require further investigation.

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.

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

Objective

Few studies have reported the surgical treatment of carotid in-stent restenosis (ISR), more data and longer follow-up are needed. We describe the surgical treatment of ISR by standard carotid endarterectomy (CEA) with stent removal, including long-term follow-up in 10 patients from our centre.

Methods

Ten patients from our centre who underwent CEA with stent removal for ISR were retrospectively analysed, including nine symptomatic and one asymptomatic ISR of at least 70% with mean age 67.3, the median time between carotid artery stenting and CEA was 17 months (range, 2–54 months).

Results

Standard CEA with stent removal was performed in all 10 patients without much technical difficulty (9 male and 1 female, mean age 67.3). Two cases were performed in hybrid operation room. There were a total of three complications that happened in three patients (30%) respectively. An asymptomatic dissecting aneurysm was formed on the petrous internal carotid artery in one patient who was followed up without intervention. In the second case, dissection occurred in the arterial wall distal to the site of the stent after stent removal revealed by intraoperative angiography, and another stent was implanted. The patient sustained temporary hypoglossal nerve dysfunction postoperatively. The third patient suffered cerebral hyperperfusion with complete recovery when discharged. No neurological complications occurred in other seven patients. After follow-up of 25 months (range, 11–54 months), one patient died of rectal cancer without ischaemic attack and restenosis 4 years postoperation; in one patient occurred recurrent symptomatic restenosis (90%) 1 year later; all other patients remained asymptomatic and without recurrent restenosis (>50%) by follow-up carotid ultrasound or CT angiography.

Conclusion

It seems that CEA with stent removal is a reasonable choice, by experienced hand, for symptomatic ISR with higher but acceptable complications. The indication of stent removal for asymptomatic ISR needs further observation.

Restenosis after carotid artery stenting

As a common etiology for ischemic stroke, atherosclerotic carotid stenosis has been targeted by vascular surgery since 1950s. Compared with carotid endarterectomy, carotid angioplasty and stenting (CAS) is almost similarly efficacious and less invasive. These advantages make CAS an alternative in treating carotid stenosis. However, accumulative evidences suggested that the long-term benefit-risk ratio of CAS may be decreased or even neutralized by the complications related to in-stent restenosis (ISR). Therefore, investigating the mechanisms and identifying the influential factors of ISR are of vital importance for improving the long-term outcomes of CAS. As responses to intrinsic and extrinsic injuries, intimal hyperplasia and vascular smooth muscle cell proliferation have been regarded as the principle mechanisms for ISR development. Due to the lack of consensus-based definition and consistent follow-up protocol, the reported incidences of ISR after CAS varied widely among studies. These variations made the inter-study comparisons of ISR largely illogical. To eliminate restenosis after CAS, both surgery and endovascular procedures have been attempted with promising results. For preventing ISR, drug-eluting stents and antiplatelets have been proposed as potential solutions.

In-Stent Restenosis After Carotid Artery Stenting: From Diagnosis to Treatment

Although carotid artery stenting is a safe and effective treatment for preventing ischaemic stroke in significant carotid atherosclerotic disease, it can be complicated by in-stent restenosis (ISR). Factors involved in the ISR process are both mechanical and patient-related, but the most important is the neointimal thickening within stent struts, leading to lumen reduction. Overall incidence of carotid ISR is low and related embolic risk seems to be lower than native disease. Digital subtraction angiography is the gold standard for diagnosis. Nowadays, Doppler ultrasound should be considered the first-line investigation, due to its non-invasiveness and reproducibility. Computed tomography angiography remains useful when Doppler ultrasound is inconclusive. Indication and modality of treatment of ISR are still debated: both surgery (carotid endarterectomy with stent removal in most cases) or interventional procedures such as percutaneous transluminal angioplasty with simple balloon, cutting-balloon, drug-eluting balloon, and stenting, showed safety and efficacy in follow-up. Surgery is currently reserved for selected cases. Carotid ISR is an overall rare complication which can be easily identified at routine follow-up. This paper is a literature review and state-of-the-art assessment of ISR, clinical features, diagnosis, and treatment.

Outcomes of 1000 Carotid Wallstent Implantations

Purpose: To evaluate the outcomes of carotid artery stenting (CAS) with Wallstents in a single-center experience. Methods: From January 2003 to December 2013, 1000 carotid artery lesions were treated with Carotid Wallstents under cerebral protection in 877 patients (mean age 71.7±8 years; 621 men). Indications for treatment were de novo lesions (>70% asymptomatic and >60% symptomatic); stenoses following carotid endarterectomy, radiation, or neck surgery; contralateral laryngeal nerve palsy; and high surgical risk. All the patients underwent duplex ultrasound and clinical evaluation during follow-up; radiography was performed when fracture or stent migration was suggested by ultrasound. Results: Procedure success was achieved in 99.3% of patients. Major and minor 30-day adverse events occurred in 2.1% of patients, including stroke (1.8%: 1.3% minor, 0.5% major), myocardial infarction (0.1%), and death (0.2%). Plaque morphology, nature of stenosis, and symptomatic status were significantly associated with the risk of postoperative neurologic events. Restenosis occurred in 3.2% at a mean 45.5-month follow-up and was significantly associated with diabetes, smoking, symptomatic stenosis, de novo stenosis, and calcification (plaque III/IV). No fracture or migration was registered during follow-up. Conclusion: CAS is a valid method for treating carotid artery disease, with very low rates of major adverse events and neurologic complications. The Carotid Wallstent seems to have excellent results, even with complex plaque morphology, and a low incidence of restenosis at follow-up.

Percutaneous Treatment of Recurrent In-Stent Restenosis of Carotid Artery Stenting: A Case Report and State-of-the-Art Review

Patient: Male, 76

Final Diagnosis: Carotid in-stent restenosis

Symptoms: None

Medication: —

Clinical Procedure: Carotid Doppler ultrasound • carotid percutaneous angioplasty

Specialty: Cardiology

The development of carotid stent material

Endovascular angioplasty with stenting is a promising option for treating carotid artery stenosis. There exist a rapidly increasing number of different stent types with different materials. The bare-metal stent is the most commonly used stent with acceptable results, but it leaves us with the problems of thrombosis and restenosis. The drug-eluting stent is a breakthrough as it has the ability to reduce the restenosis rate, but the problem of late thrombosis still has to be addressed. The biodegradable stent disappears after having served its function. However, restenosis and degradation rates remain to be studied. In this article, we review every stent material with its characteristics, clinical results and complications and point out the standards of an ideal carotid stent.