Incidence Of Recurrent Carotid Stenosis Research Articles

Follow-up Outcomes of Self-Expanding Stents for Carotid Artery Angioplasty at a Single Hospital

Carotid artery angioplasty and stent placement (CASP) is widely accepted as a valuable alternative to carotid endarterectomy, particularly among high-risk patient populations. We analyzed the follow-up data of patients who underwent CASP with self-expanding stents for carotid lesions. Since 2001, self-expanding stents have been deployed in 59 lesions in 56 patients. Forty-seven patients were male, and nine were female. The median age was 73 years, ranging 50 to 83 years. There were 31 asymptomatic lesions and 28 symptomatic lesions. The median follow-up period was 27 months, ranging six to 102 months. All lesions received stents and technical success was achieved in 58 (98.3%) out of 59 lesions. The 30-day transient ischemic attack rate was 8.6%, the stroke rate was 3.4%, and the death rate was 0%. No ischemic attack was observed on the ipsilateral side after 30 days. Recurrent stenosis (>50%) was observed in three patients (5.1%) and in two (3.4%) of these, revascularization was performed. Kaplan-Meier analysis showed that the rates for one year and two year freedom from any stroke or death were 93.1% and 90.9%, respectively. The incidence of recurrent carotid stenosis is acceptably low after CASP. CASP is effective to prevent ipsilateral ischemic stroke in symptomatic and asymptomatic patients.

Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial

The SPACE trial is a multinational, prospective, randomised study to test the hypothesis that carotid artery stenting is not inferior to carotid endarterectomy for treating patients with severe symptomatic carotid artery stenosis. We did not prove non-inferiority of carotid artery stenting compared with carotid endarterectomy for the 30-day complication rate, and we now report the results at 2 years. Between March, 2001, and February, 2006, patients with symptomatic, severe (>or=70%) carotid artery stenosis were recruited to this non-inferiority trial and randomly assigned with a block randomisation design to have carotid artery angioplasty with stenting or carotid artery endarterectomy. 2-year endpoints include several clinical endpoints and the incidence of recurrent carotid stenosis of at least 70%. Clinical and vascular follow-up was done by a certified neurologist. Analyses were by intention to treat and per protocol. This trial is registered with ISRCTN, number 57874028.12. 1 214 patients were randomly assigned (613 were randomly assigned to carotid angioplasty with stenting and 601 were randomly assigned to carotid endarterectomy). In both the intention-to-treat and per-protocol analyses the Kaplan-Meier estimates of ipsilateral ischaemic strokes up to 2 years after the procedure and any periprocedural stroke or death do not differ between the carotid artery stenting and the carotid endarterectomy groups (intention to treat 9.5%vs 8.8%; hazard ratio (HR) 1.10, 95%CI 0.75 to 1.61; log-rank p=0.62; per protocol 9.4%vs 7.8%; HR 1.23, 95%CI 0.82 to 1.83; log-rank p=0.31). In both the intention-to-treat and per-protocol populations, recurrent stenosis of 70% or more is significantly more frequent in the carotid artery stenting group compared with the carotid endarterectomy group, with a life-table estimate of 10.7% versus 4.6% (p=0.0009) and 11.1% versus 4.6% (p=0.0007), respectively. Only two incidences of recurrent stenoses after carotid artery stenting led to neurological symptoms. After 2 years' follow-up, the rate of recurrent ipsilateral ischaemic strokes reported in the SPACE trial is similar for both treatment groups. The incidence of recurrent carotid stenosis at 2 years, as defined by ultrasound, is significantly higher after carotid artery stenting. However, it cannot be excluded that the degree of in-stent stenosis is slightly overestimated by conventional ultrasound criteria.

Endovascular and surgical management of carotid artery restenosis

The incidence of recurrent carotid stenosis after primary endarterectomy ranges from 10-34%. We presented our four year experience and comparing reoperation versus endovascular treatment. In period from 2001 to 2005, 50 patients, 37 men and 13 women, were treated surgically and endovascular due to restenosis. There were no minor or major stroke, death and myocardial infarction periprocedural and in first 30 days in either group. In endovascular group one patients 3.17% had transient ischemic attack and two patients 11.76% in surgical group. One patient died from myocardial infraction in follow up in surgical group. There were no restenosis > or = 50% in endovascular group, two patients have restenosis > or = 50% in surgical group. Endovascular treatment of carotid artery restenosis represents a safe and efficient way of treatment, connected with minor number of serious complications than redo operation.

Restenosis after carotid endarterectomy

Multiple randomised trials over the last decade for both symptomatic and asymptomatic carotid stenosis have proven the efficacy of carotid endarterectomy (CE) in reducing the risk of stroke. The long-term patency of the carotid artery after CE is an important factor in the success of the operation. The incidence of recurrent carotid stenosis (excluding residual lesions) ranges from 1 to 37% with only 0-8% of patients having restenosis-related symptoms (1). Generally, recurrent carotid stenosis is attributed to myointimal hyperplasia during the early postoperative period (within 3 years) or recurrent atherosclerosis thereafter. The management of recurrent carotid stenosis after CE remains a dilemma. It is generally accepted that operation for significant recurrent carotid stenosis is indicated for symptomatic patients, and several authors also recommend CE for >80% asymptomatic recurrent stenosis. Treatment of recurrent carotid stenosis involves repeat endarterectomy with patch angioplasty, although more recently endovascular techniques have been used.

Systematic Review of Early Recurrent Stenosis After Carotid Angioplasty and Stenting

Carotid angioplasty and stenting (CAS) has emerged as a potential alternative to endarterectomy (CEA) for the treatment of carotid artery disease. Aside from the periprocedural complication rates, the benefits of CAS will be affected by the incidence of recurrent carotid stenosis. We conducted a systematic analysis of all peer-reviewed studies reporting on the rate of restenosis (> or =50%) after CAS based on duplex ultrasound or angiography that were published between January 1990 and July 2004. We identified 34 studies that reported on a total of 4185 patients with a follow-up of 3814 arteries over a median of 13 months (range, 6 to 31 months). The ultrasound criteria and the lower thresholds for defining a recurrent stenosis were very heterogeneous. The cumulative restenosis rates after 1 and 2 years were approximately 6% and 7.5% in those studies, which used a lower restenosis threshold > or =50% to 70% and approximately 4% in the first 2 years after CAS in those studies, which used a lower restenosis threshold >70% to 80%. In reviewing the current literature, the early restenosis rates after CAS compare well with those reported for CEA. However, this analysis of the peer-reviewed literature also indicates that the early restenosis rates after CAS might be higher than previously suggested in observational surveys. Therefore, an active follow-up of all stented arteries seems to be warranted. Moreover, the bulk of endovascular data are derived from small studies with short follow-up periods so that the long-term durability of CAS still needs to be established in large trials. Ideally, these studies should use a clear and uniform definition of restenosis and identical follow-up schedules.

An outcome analysis of carotid endarterectomy: The incidence and natural history of recurrent stenosis

This report identifies the incidence of recurrent carotid stenosis after carotid endarterectomy (CEA) and records the natural history of the disease process to gain further insight into its proper management. A prospective surveillance protocol with duplex imaging and velocity spectral analysis was used to detect recurrent stenosis ( > 50% diameter reduction) and to document the clinical outcomes of patients who underwent CEA. Between 1984 and 1993, 619 consecutive CEAs were performed in 587 patients. Recurrent carotid stenosis developed in 48 CEA sites (7.8%) during a mean follow-up interval of 34 months (range, 2 to 118 months). Normal results on intraoperative assessment correlated with a 5.6% incidence of recurrent stenosis, compared with a 19% incidence when a residual hemodynamic abnormality was present (p < 0.0003). In the first year after surgery, there were no transient ischemic attacks, strokes, or carotid occlusions from recurrent stenosis, compared with a 27% morbidity rate in later follow-up (p < 0.01). Three patients with recurrent stenosis subsequently had occlusion at the CEA site, two of whom had severe ipsilateral strokes. The incidence of recurrent carotid stenosis is low. Patients are at significant risk for neurologic morbidity when a recurrent stenosis occludes. With a 0.3% incidence of late stroke resulting from carotid bifurcation disease, these data confirm that CEA does provide long-term protection from stroke.

The effect of lipid lowering on the incidence of recurrent carotid stenosis

The effect of lipid lowering on the incidence of recurrent carotid stenosis

Is duplex follow-up cost-effective in the first year after carotid endarterectomy?

Recent reports have suggested that duplex scanning is an ideal method to noninvasively assess the incidence of recurrent carotid stenosis. However, the timing and frequency of the follow-up studies are controversial. In the present study, 150 patients underwent 173 carotid endarterectomy procedures over a 2 year period. In the postoperative period, a total of 210 duplex studies were carried out on 117 carotid arteries. 21.4 percent of the 117 arteries studied had recurrent stenosis of 16 percent or greater at a mean postoperative follow-up of 15.2 +/- 3 months. Recurrent stenoses were detected early after operation; 96 percent were detected at or before 15 months postoperatively. Patients with recurrent stenoses remained stable and had infrequent symptoms. Several risk factors placed the patient at increased risk for recurrent carotid stenosis: presence of contralateral disease (defined as stenosis of 50 percent or greater), use of tacking sutures, and continued smoking in the postoperative period. Although it remains important for researchers to thoroughly investigate the natural history of atherosclerosis of the extracranial carotid artery, including those changes that occur after carotid endarterectomy, our results indicate that frequent duplex scanning in the first postoperative year is unnecessary and is not cost-effective. Duplex follow-up studies 1 and 12 months after carotid endarterectomy are sufficient for assessing the problem of recurrent stenosis in the first postoperative year.

Late patency of the carotid artery after endarterectomy. Problems of definition, follow-up methodology, and data analysis

To determine the relative incidence of recurrent carotid stenosis (RCS) and the effect of methodology on data analysis and interpretation, late results were obtained for 232 patients (270 procedures) from 1 to 51 months (mean 22 months) after carotid endarterectomy (group A). Patency of the carotid artery was confirmed by postoperative intravenous digital subtraction angiography (DSA) for most of the series, and a subset (subgroup A1) of 113 patients (129 procedures) also received DSA studies at later intervals of 4 to 49 months (mean 26 months). There were 23 late deaths and five late strokes. Only two of the strokes were ipsilateral to previous endarterectomy, and both of these patients had normal follow-up DSA studies. Late DSA imaging revealed either no RCS or only trivial defects (20% diameter or less) in 111 arteries, moderate (36% to 60%) RCS in nine, severe (70% to 90%) RCS requiring secondary procedures in eight, and internal carotid occlusion in one. Depending on the definition of RCS (secondary operation vs ⩾30% angiographic lesions), the cohort selected for analysis (group A vs subgroup A1), and the approach to calculations (crude vs cumulative), the incidence of recurrent stenosis after carotid reconstruction in this single study could be expressed within the extraordinarily wide range of 3% to 32%. Although carotid endarterectomy was associated with uniformly low risk for late stroke, these results confirm that the reported recurrence rate may be substantially influenced by the method in which data are grouped and manipulated. Consistently presented data are essential to any comparisons concerning the surgical therapy for extracranial disease.

Recurrent stenosis after carotid endarterectomy.

The true incidence of recurrent carotid stenosis is unknown. Most reports provide only anecdotal data. Reported incidences, which range from 0.6% to 9.8%, reflect the care with which the search for recurrent stenosis was made by individual reporters. Early restenosis occurring within less than 24 months is characterized by a fibrous hyperplastic reaction, whereas stenoses occurring beyond this time are usually caused by typical atherosclerotic lesions. Although no clear risk factors can be identified, surgical trauma and inadequate endarterectomy are likely predisposing causes. Reoperation is technically more difficult and a patch graft, preferably vein, is often necessary. Careful postoperative evaluation and a search for the possibility of recurrent stenosis is recommended, especially in view of the increasing frequency of prophylactic carotid endarterectomy.