Clinical impact and predictors of carotid artery in-stent restenosis

Katrin Wasser,Peter Schramm,Marios-Nikos Psychogios,Michael Knauth,Sonja Schnaudigel,Janin Wohlfahrt,Klaus Gröschel

doi:10.1007/s00415-012-6436-3

Katrin Wasser, Peter Schramm + Show 5 more

Open Access

https://doi.org/10.1007/s00415-012-6436-3

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Abstract

To assess the incidence and clinical significance as well as predictors of in-stent restenosis (ISR) after carotid artery stenting (CAS) diagnosed with serial duplex sonography investigations. We analyzed 215 CAS procedures that had clinical and serial carotid duplex ultrasound investigations. The incidence of in-stent restenosis (ISR) and periprocedural as well as long-term clinical complications were recorded. The influence of an ISR on clinical complication was analyzed using Kaplan-Meier curves and clinical risk factors for the development of an ISR with multivariate logistic regression. During a median follow-up time of 33.4 months (interquartile range 15.3–53.7) an ISR of ≥70% was detected in 12 (6.1%) of 215 arteries (mean age of 68.1 ± 9.8 years, 71.6% male). The combined stroke and death rate during long-term follow-up was significantly higher in the group with an ISR [odds ratio (OR): 3.59, 95% confidence interval (CI): 1.50–8.59, p = 0.004]. After applying multivariate logistic regression analysis contralateral carotid occlusion (OR 10.11, 95% CI 2.06–49.63, p = 0.004), carotid endarterectomy (CEA) restenosis (OR 8.87, 95% CI 1.68–46.84, p = 0.010) and postprocedural carotid duplex ultrasound with a PSV ≥120 cm/s (OR 6.33, 95% CI 1.27–31.44, p = 0.024) were independent predictors of ISR. ISR after CAS during long-term follow-up is associated with a higher proportion of clinical complications. A close follow-up is suggested especially in those patients with the aforementioned independent predictors of an ISR. Against the background of a lacking established treatment of ISR, these findings should be taken into account when offering CAS as a treatment alternative to CEA.

Highlights

Atherosclerotic stenosis of the carotid artery is known as a major risk factor for ischaemic stroke
The combined stroke and death rate during long-term follow-up was significantly higher in the group with an in-stent restenosis (ISR) [odds ratio (OR): 3.59, 95% confidence interval (CI): 1.50–8.59, p = 0.004]
According to the current literature a carotid artery stenting (CAS) intervention is thought to be effective in younger patients, because two meta-analyses comparing the complications of CAS and carotid endarterectomy (CEA) showed a trend towards a favorable outcome in patients aged \70 years for those patients treated with CAS [1, 4]

Summary

Introduction

Atherosclerotic stenosis of the carotid artery is known as a major risk factor for ischaemic stroke. Carotid endarterectomy (CEA) in combination with best medical treatment of cerebrovascular risk factors is considered to be the gold standard for primary and secondary stroke prevention in patients with significant carotid artery stenosis. Carotid angioplasty and stenting (CAS) have emerged as a potentially less invasive treatment alternative. A current major drawback is that prospective data with respect to the clinical long-term outcome are sparse and controversially discussed [1]. The occurrence of an in-stent restenosis (ISR) could endanger the long-term efficacy and safety of CAS. Considering the fact that to date there is no established treatment strategy for an ISR, this issue will be of high clinical importance if

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