Carotid Endarterectomy for Treatment of Instent Restenosis

Abstract

Carotid stenting is now an established option in the treatment of carotid stenosis. Recurrent stenosis following carotid stenting, however, can be a management challenge. Repeat angioplasty may be ineffective or result in recurrent instent stenosis. Obtaining distal control of the internal carotid artery above the stented segment may be difficult. Instent restenosis was encountered in three patients who underwent successful surgical endarterectomy of the stented segment. A 69-year-old gentleman who had undergone right carotid stenting for a symptomatic >80% stenosis 2 years before presented with symptoms of a right hemispheric TIA manifested by left limb paraplegia. Restenosis of the common carotid artery was identified by duplex ultrasound and confirmed by arteriography. The common carotid was thought to be too tortuous for repeat angioplasty. Operative therapy, therefore, was undertaken. The stent was opened longitudinally with the arteriotomy extending to the distal internal carotid in a standard fashion. Endarterectomy of the plaque and stent was performed around a 12F shunt. The artery was closed with a saphenous vein patch. The stent was well incorporated within the plaque (Fig 1). No cranial nerve deficits were noted. At 30 days the patient was stable with no evidence of carotid stenosis on duplex ultrasound. A 79-year-old gentleman who underwent left carotid stenting for symptomatic severe stenosis presented with recurrent left hemispheric symptoms 4 years later. Severe >90% instent restenosis was noted on duplex ultrasound and confirmed by computed topographic angiography. Carotid endarterectomy was performed around a 12F shunt with removal of the stent and plaque. The artery was closed with a dacron patch. At 30 days, duplex ultrasound revealed no evidence of restenosis. An 86-year-old lady who had undergone right carotid stenting for a symptomatic lesion returned 1 year later with severe symptomatic instent restenosis. Duplex ultrasound confirmed a 75% stenosis at the distal end of the stent. Repeat percutaneous therapy was avoided because of vessel tortuosity and technical difficulties during the first procedure. An endarterectomy of the plaque and stent with dacron patch angioplasty was performed without complication. At 30 days, duplex ultrasound revealed no evidence of restenosis. Considering the popularity of carotid stenting, an increasing number of “high risk” patients are at risk for restenosis. These three patients were all deemed “high risk” for surgical endarterectomy, yet subsequently underwent carotid endarterectomy without complication, calling into question the current inclusion criteria for “high risk” patients. Although carotid resection with interposition graft repair has been described for treatment of recurrent instent stenosis, this is the first report of surgical endarterectomy which includes the stented segment. The stents were easily removed within the endarterectomy specimens using standard surgical technique. These cases demonstrate that carotid endarterectomy can be safely performed for recurrent instent stenosis if the distal end of the stent can be surgically controlled. Longer surveillance is necessary to determine the patency of this procedure.