Endarterectomy versus stenting in patients with prior ipsilateral carotid artery stenting

• Published in: Journal of vascular surgery Vol. 65; no. 5; pp. 1418 - 1428
• Main Authors: Arhuidese, Isibor J., MD, MPH, Nejim, Besma, MD, MPH, Chavali, Susruth, MD, Locham, Satinderjit, MD, Obeid, Tammam, MD, Hicks, Caitlin W., MD, MS, Malas, Mahmoud B., MD, MHS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.05.2017
• Subjects: Aged; Angioplasty - adverse effects; Angioplasty - instrumentation; Angioplasty - mortality; Carotid Stenosis - diagnostic imaging; Carotid Stenosis - mortality; Carotid Stenosis - surgery; Carotid Stenosis - therapy; Chi-Square Distribution; Databases, Factual; Disease-Free Survival; Endarterectomy, Carotid - adverse effects; Endarterectomy, Carotid - mortality; Female; Humans; Kaplan-Meier Estimate; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Patient Selection; Proportional Hazards Models; Recurrence; Retreatment; Retrospective Studies; Risk Assessment; Risk Factors; Stents; Surgery; Time Factors; Treatment Outcome
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2016.11.041

Abstract Objective In-stent restenosis is a recognized complication of carotid angioplasty and stenting (CAS), and it is associated with an increased risk of stroke. Few case series have reported outcomes separately following carotid endarterectomy (CEA) and CAS for the treatment of in-stent restenosis. In this study, we perform an evaluation of redo-CAS vs CEA in a large contemporary cohort of patients who underwent prior ipsilateral CAS. Methods We studied all patients in the Vascular Quality Initiative (VQI) database, who underwent CEA or CAS between January 1, 2003, and April 30, 2016, after prior ipsilateral CAS. Univariate methods ( χ2 , t -test), Kaplan-Meier, logistic, and Cox regression analyses adjusting for patient characteristics were employed to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days and up to 1 year following the procedure. Results There were 645 carotid interventions (CEA, 134 [21%] and redo-CAS, 511 [79%]) performed in this cohort of patients with prior ipsilateral CAS. Postoperative stroke within 30 days comparing CEA vs CAS was 0% vs 0.3% ( P  = .61) for asymptomatic patients and 4.4% vs 3.5% ( P  = .79) for symptomatic patients for an overall stroke rate of 1.5% vs 1.4%. MI was 2.3% vs 1.2% ( P  = .35), 30-day mortality was 3.7% vs 0.9% ( P  = .02) following CEA vs CAS, whereas the composite of perioperative stroke/death was 4.5% vs 1.9% ( P  = .09). Freedom from stroke/death at 1 year was 91% for CEA and 92% for redo-CAS ( P  = .76). After risk adjustment, there was no significant difference in 30-day stroke (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.15-4.48; P  = .82), mortality (OR, 2.21; 95% CI, 0.54-9.11; P  = .27), or stroke/death (OR, 0.99; 95% CI, 0.26-3.84; P  = .99) as well as 1-year stroke (hazard ratio [HR], 0.60; 95% CI, 0.13-2.85; P  = .52), mortality (HR, 0.83; 95% CI, 0.42-1.65; P  = .60), or stroke/death (HR, 0.80; 95% CI, 0.43-1.49; P  = .48) comparing CEA with CAS. The significant predictors of perioperative stroke/death were older age, diabetes, active smoking, and preoperative American Society of Anesthesiologists class IV status (all P  < .05). Conclusions We have reported adverse event rates for CEA and CAS after prior CAS and shown no significant difference in perioperative and 1-year outcomes between both groups. However, CEA is offered to patients who are more severely ill than redo-CAS, resulting in significantly higher absolute mortality. We recommend avoidance of CEA especially in asymptomatic patients with serious systemic disease. Tight management of diabetes and smoking cessation remain potent targets for outcomes improvement in redo-CAS patients.