In-stent recurrent stenosis after carotid artery stenting: life table analysis and clinical relevance

• Published in: Journal of vascular surgery Vol. 38; no. 6; pp. 1162 - 1168
• Main Authors: Lal, Brajesh K, Hobson, Robert W, Goldstein, Jonathan, Geohagan, Madge, Chakhtoura, Elie, Pappas, Peter J, Jamil, Zafar, Haser, Paul B, Varma, Shubha, Padberg, Frank T, Cerveira, Joaquim J
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 01.12.2003
• Subjects: Aged; Blood Vessel Prosthesis Implantation - adverse effects; Carotid Stenosis - surgery; Female; Follow-Up Studies; Graft Occlusion, Vascular - epidemiology; Graft Occlusion, Vascular - etiology; Graft Occlusion, Vascular - therapy; Humans; Incidence; Life Tables; Male; Middle Aged; Prospective Studies; Stents - adverse effects; Time Factors
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2003.08.021

Carotid artery stenting has been proposed as an alternative to carotid endarterectomy in cerebral revascularization. Although early results from several centers have been encouraging, concerns remain regarding long-term durability of carotid artery stenting. We report the incidence, characteristics, and management of in-stent recurrent stenosis after long-term follow-up of carotid artery stenting. Carotid artery stenting (n = 122) was performed in 118 patients between September 1996 and March 2003. Indications included recurrent stenosis after previous carotid endarterectomy (66%), primary lesions in patients at high-risk (29%), and previous ipsilateral cervical radiation therapy (5%). Fifty-five percent of patients had asymptomatic stenosis; 45% had symptomatic lesions. Each patient was followed up with serial duplex ultrasound scanning. Selective angiography and repeat intervention were performed when duplex ultrasound scans demonstrated 80% or greater in-stent recurrent stenosis. Data were prospectively recorded, and were statistically analyzed with the Kaplan-Meier method and log-rank test. Carotid artery stenting was performed successfully in all cases, with the WallStent or Acculink carotid stent. Thirty-day stroke and death rate was 3.3%, attributable to retinal infarction (n = 1), hemispheric stroke (n = 1), and death (n = 2). Over follow-up of 1 to 74 months (mean, 18.8 months), 22 patients had in-stent recurrent stenosis (40%-59%, n = 11; 60%-79%, n = 6; ≥80%, n = 5), which occurred within 18 months of carotid artery stenting in 13 patients (60%). None of the patients with in-stent recurrent stenosis exhibited neurologic symptoms. Life table analysis and Kaplan-Meier curves predicted cumulative in-stent recurrent stenosis 80% or greater in 6.4% of patients at 60 months. Three of five in-stent recurrent stenoses occurred within 15 months of carotid artery stenting, and one each occurred at 20 and 47 months, respectively. Repeat angioplasty was performed once in 3 patients and three times in 1 patient, and repeat stenting in 1 patient, without complications. One of these patients demonstrated asymptomatic internal carotid artery occlusion 1 year after repeat intervention. Carotid artery stenting can be performed with a low incidence of periprocedural complications. The cumulative incidence of clinically significant in-stent recurrent stenosis (≥80%) over 5 years is low (6.4%). In-stent restenosis was not associated with neurologic symptoms in the 5 patients noted in this cohort. Most instances of in-stent recurrent stenosis occur early after carotid artery stenting, and can be managed successfully with endovascular techniques.