The management of carotid restenosis: a comprehensive review

Carotid artery stenosis (CS) is a major medical problem affecting approximately 10% of thegeneral population 80 years or older and causes stroke in approximately 10% of all ischemic events. Inpatients with symptomatic, moderate-to-severe CS, carotid endarterectomy (CEA) and carotid angioplastyand stenting (CAS), has been used to lower the risk of stroke. In primary CS, CEA was found to be superiorto best medical therapy (BMT) according to 3 large randomized controlled trials (RCT). Following CEAand CAS, restenosis remains an unsolved problem involving a large number of patients as the currenttreatment recommendations are not as clear as those for primary stenosis. Several studies have evaluated therisk of restenosis, reporting an incidence ranging from 5% to 22% after CEA and an in-stent restenosis (ISR)rate ranging from 2.7% to 33%. Treatment and optimal management of this disease process, however, is amatter of ongoing debate, and, given the dearth of level 1evidence for the management of these conditions,the relevant guidelines lack clarity. Moreover, the incidence rates of stroke and complications in patientswith carotid stenosis are derived from studies that did not use contemporary techniques and materials.Rapidly changing guidelines, updated techniques, and materials, and modern medical treatments make actualincidence rates barely comparable to previous ones. For these reasons, RCTs are critical for determiningwhether these patients should be treated with more aggressive treatments additional to BMT and identifyingthose patients indicated for surgical or endovascular treatments. This review summarizes the currentevidence and controversies concerning the risks, causes, current treatment options, and prognoses in patientswith restenosis after CEA or CAS.