Vaskulárna medicína 1/2022

Endovascular treatment of restenosis after carotid endarterectomy and carotid artery stenting

Purpose: Carotid artery stenosis is a major medical problem causing stroke in approximately 10 – 15 % of all ischemic events. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) has been used to lower the risk of stroke. Restenosis remains an unsolved problem involving a large number of patients. Treatment and optimal management of this disease process is a matter of ongoing debate. Materials and methods: Between 2013 and 2019, 19 endovascular procedures were performed for restenosis of carotid artery at our department in 15 patients, including 9 patients after CEA and 6 patients after CAS. Restenosis was primarily diagnosed during a routine ultrasound examination and was confirmed by preprocedural angiography. Patient medical data, preprocedural, intraprocedural data, and follow-up results were evaluated. This article summarizes our experience, current evidence and controversies related to the risks, causes, current treatment options, and prognoses in patients with restenosis after CEA or CAS. Results: Ten of the patients were men (67 %), median age 68 years (interquartile range (IQR) 62 – 71). Median time to reintervention was 10 months (IQR 6 – 63,5). Median follow-up after reintervention was 43 months (IQR 15,5 – 63,5). Among patients treated for restenosis after CEA, recurrent significant restenosis occurred in one patient (11 %) and was treated with angioplasty, followed by stenting for another recurrence of restenosis. Significant recurrence of restenosis was treated in two patients after CAS with stent implantation. The incidence of at least mild (above 50 %) restenosis at the end of follow-up was significantly higher in patients treated for restenosis after CAS than after CEA (50 % [3/6] vs 0 % [0/9], p = 0.044). Conclusion: For post-CEA restenosis, current literature suggests CAS as a preferred method. Asymptomatic restenosis after CAS should be treated medically, as the risk of stroke is minimal. Symptomatic in-stent restenosis after CAS can be treated by means of endovascular or surgical techniques. Repeated CAS has low postoperative and long-term risk. Percutaneous transluminal angioplasty may be less recommended in case of restenosis after CAS due to the relatively high long-term risks of transient ischemic attack, and stroke. Endovascular techniques have a relatively high incidence of recurrent restenosis, which is consistent with our results.

Keywords: carotid artery stenosis, restenosis, carotid artery stenting, carotid endarterectomy