Carotid endarterectomy for treatment of in-stent restenosis after carotid angioplasty and stenting

Objective: Carotid angioplasty and stenting (CAS) has emerged as an alternative for carotid endarterectomy (CEA) in the prevention of stroke. The benefit of the procedure, however, is hampered by a suggested higher incidence of in-stent restenosis (ISR) for CAS relative to CEA during follow-up. ISR management remains a challenge for clinicians. In this observational retrospective analysis, we evaluated the operative management of ISR by standard CEA with stent removal, including midterm follow-up in 15 patients. Methods: The present analysis included 15 patients from three Dutch vascular centers who underwent CEA for symptomatic (n = 10) or hemodynamically significant (<80%) asymptomatic ISR (n = 5). Median time between CAS and CEA was 18.3 months (range, 0-51 months). Results: Standard CEA with stent removal was performed in all 15 patients. A Javid shunt was used in two procedures. One patient sustained an intraoperative minor ischemic stroke, with complete recovery during the first postoperative days. No neurologic complications occurred in the other 14 patients. Two patients required a reoperation to evacuate a neck hematoma. There were no peripheral nerve complications. After a median follow-up of 21 months (range, 3-100 months), all 15 patients remained asymptomatic and without recurrent restenosis (<50%) on duplex ultrasound imaging. Conclusion: CEA with stent explantation for ISR after CAS seems an effective and durable therapeutic option, albeit with potential cerebral and bleeding complications, as in this study. The optimal treatment for carotid ISR, however, has yet to be defined.

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