Anatomical and Technical Factors Influence the Rate of In-Stent Restenosis following Carotid Artery Stenting for the Treatment of Post-Carotid Endarterectomy Stenosis (original) (raw)
Related papers
In-stent Restenosis After Carotid Angioplasty and Stenting: A Challenge for the Vascular Surgeon
European Journal of Vascular and Endovascular Surgery, 2005
Purpose. This study aims to review the incidence of in-stent restenosis (ISR), the factors which determine restenosis, and to evaluate the use of various endovascular techniques for the management of ISR following carotid artery stenting (CAS). Methods. Four hundred and seven patients (334 men, mean age 63 years, range 46-86, median 65 years) were treated with CAS between December 2000 and March 2004. Three hundred and seventy-two (89%) patients had at least one ultrasound evaluation performed 6 months after procedure (range 6-40). Recurrent stenosis O80% detected with duplex ultrasound scans were further evaluated by angiography and treated with repeat endovascular procedure. Results. CAS was performed successfully in all cases with a Carotid WallStent (Boston Scientific) using a cerebral protection device (filter). Perioperative complications included four (0.9%) minor and two (0.4%) major strokes these latter two patients died at 5 and 12 days after the operation. No other deaths occurred. A total of 15 carotid arteries (3.6%) in 14 patients had ISR. All ISR were treated with a repeat endovascular procedure: three balloon angioplasty alone, eight angioplasty and secondary stenting, four angioplasty with cutting balloon. Postsurgical restenosis was confirmed to be the only predictive factor for the development of in-stent restenosis (OR 14.5, 95% CI 2.3-113.4, pZ0.005). Endovascular treatment of ISR achieved technical success without periprocedurale complications and the absence of significant restenosis over a median follow up time of 12.4 months (range 3.5-30.7). Conclusion. Our experience with a large cohort of CAS showed an encouragingly low incidence of ISR (3.6%) and successful treatment by repeat endovascular intervention. We recommend attempting all endovascular possibilities before performing stent removal.
Operative management of carotid artery in-stent restenosis: First experiences and duplex follow-up
European Journal of Vascular and Endovascular Surgery, 2003
Objectives: Carotid Artery Stenting (CAS) may be comparable to Carotid Endarterectomy (CEA) as a durable and effective procedure in stroke prevention. Concern remains about the incidence of restenosis after stenting and its management. We evaluated the surgical managment of restenosis after CAS. Design: Prospective study Methods: Between December 1997 and april 2001, 217 CAS procedures were performed in 217 patients (155 men and 62 women; age 70 years ± 8.2). After a mean of 8 months post-stenting four patients (2 symptomatic, 2 asymptomatic with contralateral occlusion) with severe haemodynamic instent restenosis (90-99%) had surgical reintervention Results: Standard CEA with removal of the stent was performed in all 4 patients.
In-Stent Restenosis After Carotid Artery Stenting: From Diagnosis to Treatment
European Medical Journal
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, c...
In Stent Restenosis Predictors after Carotid Artery Stenting
Stroke Research and Treatment, 2010
Purpose. The long-term efficacy of carotid artery stenting is debated. Predictors of stent restenosis are not fully investigated. Our aim was to assess the incidence of long term restenosis after CAS and to identify some predictors of restenosis.Methods. We retrospectively selected 189 treated patients and we obtained the survival Kaplan-Meier curves for overall survival, for freedom from stroke or death and from restenosis. To correlate clinical, radiological, and procedural variables to stent restenosis, an univariate analysis was performed while to determine independent predictors of restenosis, a multivariate analysis was applied.Results. At 1, 3, and 5 years, the cumulative overall survival rate was 98%, 94%, and 92% with a cumulative primary patency rate of 87%, 82.5%, and 82.5%. The percentage residual stenosis after CAS and multiple stents deployment were independent predictors of restenosis, while diabetes and tumors are suggestive but not significant predictors of restenos...
In-stent restenosis after carotid angioplasty-stenting: Incidence and management
Journal of Vascular Surgery, 2001
Purpose: Carotid angioplasty-stenting (CAS) has been advocated as an alternative to carotid endarterectomy (CEA) in patients with restenotic lesions after prior CEA, primary stenoses with significant medical comorbidities, and radiationinduced stenoses. The incidence of restenosis after CAS and its management remains ill defined. We evaluated the incidence and management of in-stent restenosis after CAS. Methods: Patients with asymptomatic (61%) and symptomatic (39%) carotid stenosis of ≥ 80% underwent CAS between September 1996 and May 2000; there were 50 procedures and 46 patients (26 men and 20 women). All patients were followed up clinically and underwent duplex ultrasonography (DU) at 3-to 6-month intervals. In-stent restenoses ≥ 80% detected with DU were further evaluated by means of angiography for confirmation of the severity of stenosis. Results: No periprocedural or late strokes occurred in the 50 CAS procedures during the 30-day follow-up period. One death (2.2%) that resulted from myocardial infarction was observed 10 days after discharge following CAS. During a mean follow-up period of 18 ± 10 months (range, 1-44 months), in-stent restenosis was observed after four (8%) of the 50 CAS procedures. Angiography confirmed these high-grade (≥ 80%) in-stent restenoses, which were successfully treated with balloon angioplasty (3) or angioplasty and restenting (1). No periprocedural complications occurred, and these patients remained asymptomatic and without recurrent restenosis over a mean follow-up time of 10 ± 6 months. Conclusions: We recommend CAS for post-CEA restenosis, primary stenoses in patients with high-risk medical comorbidities, and radiation-induced stenoses. In-stent restenoses occurred after 8% of CAS procedures and were managed without complications with repeat angioplasty or repeat angioplasty and restenting. (J Vasc Surg 2001;33:220-6.)
Management of in-sent restenosis after carotid artery stenting in high-risk patients
Journal of Vascular Surgery, 2006
Background: Carotid artery stenting (CAS) has emerged as an acceptable treatment alternative in patients with carotid bifurcation disease. Although early results of CAS have been promising, long-term clinical outcomes remain less certain. We report herein the frequency, management, and clinical outcome of in-stent restenosis (ISR) after CAS at a single academic institution. Methods: Clinical records of 208 CAS procedures in 188 patients with carotid stenosis of 80% or greater, including 48 (26.5%) asymptomatic patients, during a 42-month period were analyzed. Follow-up serial carotid duplex ultrasound scans were performed. Selective angiography and repeat intervention were performed when duplex ultrasound scans showed 80% or greater ISR. Treatment outcomes of ISR interventions were analyzed. Results: Over a median 17-month follow-up, 33 (15.9%) ISRs of 60% or greater were found, according to the Doppler criteria. Among them, seven patients (3.4%) with a mean age of 68 years (range, 65-87 years) developed high-grade ISR (>80%), and they all underwent further endovascular interventions. Six patients with high-grade ISR were asymptomatic, whereas one remaining patient presented with a transient ischemic attack. Five of seven ISRs occurred within 12 months of CAS, and two occurred at 18 months' follow-up. Treatment indications for initial CAS in these seven patients included recurrent stenosis after CEA (n ؍ 4), radiation-induced stenosis (n ؍ 1), and high-cardiac-risk criteria (n ؍ 2). Treatment modalities for ISR included balloon angioplasty alone (n ؍ 1), cutting balloon angioplasty alone (n ؍ 4), cutting balloon angioplasty with stent placement (n ؍ 1), and balloon angioplasty with stent placement (n ؍ 1). Technical success was achieved in all patients, and no periprocedural complications occurred. Two patients with post-CEA restenosis developed restenosis after ISR interventions, both of whom were successfully treated with cutting balloon angioplasty at 6 and 8 months. The remaining five patients showed an absence of recurrent stenosis or symptoms during a mean follow-up of 12 months (range, 3-37 months). By using the Kaplan-Meier analysis, the freedom from 80% or greater ISR after CAS procedures at 12, 24, 36, and 42 months was 97%, 97%, 96%, and 94%, respectively.
Advances in Interventional Cardiology, 2019
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.
Journal of vascular surgery, 2016
The appropriateness of percutaneous intervention for moderate to severe carotid in-stent restenosis (C-ISR) is unclear. We therefore sought to compare stroke/death/myocardial infarction (MI) rates between percutaneous interventions and nonoperative management for ≥50% C-ISR. We performed a single-center retrospective review of consecutive patients presenting with ≥50% C-ISR to the vascular surgery service. Demographics, comorbidities, and intraoperative and postoperative variables were obtained. The degree of stenosis was verified by review of digital subtraction or computed tomography angiograms. The primary outcome was stroke/death/MI after the diagnosis of ≥50% C-ISR. χ(2), Kruskal-Wallis, and Kaplan-Meier analysis was used to quantify outcomes of the patients treated percutaneously vs nonoperatively. During a 13-year period, 59 patients (75 C-ISRs) presented with ≥50% C-ISRs (n = 58 male [98%]; n = 57 C-ISRs asymptomatic [76%]) with a median age of 67.5 years (62.8-74.6). The in...
The American journal of case reports, 2015
BACKGROUND Restenosis after carotid artery stenting (CAS) is a poorly described phenomenon. Studies have reported a variable incidence ranging from 4% to 19.7% at 1 year of follow-up. Doppler Ultrasound (DUS) is now routinely used in the follow-up after CAS and endarterectomy with optimal accuracy in detecting significant restenosis, compared to digital subtraction angiography (DSA). CASE REPORT We reported the case of a 76-year-old patient with evidence of recurrent severe in-stent restenosis (ISR) of the left internal carotid artery (ICA). In April 2007, due to evidence at DUS of severe left ICA disease, the patient underwent CAS. In January 2009, due to DUS evidence of severe ISR, the patient underwent balloon angioplasty. In September 2011, DUS showed a severe ISR with a peak systolic velocity (PSV) of 436 cm/s; in June 2012 angiography showed a sub-expanded stent in the middle medial side with severe ISR (70%). Multiple inflations were performed and a slight residual sub-expans...
Carotid endarterectomy for treatment of in-stent restenosis after carotid angioplasty and stenting
Journal of Vascular Surgery, 2011
In-stent restenosis (ISR) after carotid angioplasty and stenting is becoming evident as more patients undergo carotid stenting and duplex scan surveillance. While redo endovascular therapy has been immediately successful, recurrent stenosis remains a problem. The ideal management of ISR has not been determined. Three cases of symptomatic ISR that were successfully treated by standard carotid endarterectomy (CEA) with removal of the stent are reported herein. Current options for management of ISR are reviewed from the literature.