Background: In-stent restenosis (ISR) after CAS is a relatively common complication (range 5-12%). Usually, a new endovascular intervention is proposed to treat ISR, but catheter based procedures reveal unsatisfactory long-term results, and in some cases, stent removal and carotid reconstruction are required.The aim of the present study was to review our experience with early and long-term outcomes of symptomatic patients treated for intra-stent carotid restenosis with carotid bypasses (CB).Methods: Data were retrospectively collected from a prospectively complied database on patients treated with CB in two high-volume Italian centers between 2008 and 2015, for symptomatic high-grade ISR after CAS. After carotid endarterectomy and stent removal, a greater saphenous vein (GSV) was preferentially used as the graft; when a GSV was not available, a 6mm polytetrafluoroethylene (PTFE) graft was implanted. Standard follow-up protocol in both centers included clinical examinations, duplex scans (DUS) and computed tomographic angiography (CTAs) at one month after surgery. In the absence of new clinical events, a routine duplex surveillance was scheduled at three, six and 12 months and yearly thereafter. Measures considered for analysis were perioperative (30-day) and long-term follow-up of new ipsilateral cerebral events, neurological eventsand all causes of death, and needs for reintervention. In addition, peripheral nerve palsy, cervical hematoma, and other local complications after surgery were noted.Results: The study population was comprised of 12 patients (10 men and two women; mean age 69.3 years ±10.8 years). Mean time from index CAS to stent explantation and CB was 37.7 ± 18.4 months. Surgical history of treated patients is reported in the Table. General anesthesia was performed in five (41.7%) cases; all other procedures were performed under local anesthesia (58.3%). Selective carotid shunts were required in two patients (17%). After whole stent removal, GSV grafts were employed in seven cases (58.3%) and PTFE grafts in the other five (41.7%) cases. Intraoperative neurological complication rates were null. One patient, with ISR after post-CEA restenosis, presented with a transient dysphagia. At 30-day follow-up, no new neurological complications, reinterventions or deaths occurred. At mean follow-up of 46.2±22.7 months, three patients died (two of acute myocardial infarctions and one of lung cancer), in absence of further neurological events. At DUS examinations, all CB were patents without reinterventions. One patient treated by PTFE graft developed a non-hemodynamically restenosis.Conclusions: In our experience, CB offers satisfactory results in patients treated for symptomatic ISR, with an acceptable risk of cranial nerve injuries even in patients with prior carotid surgery.
Symptomatic intrastent carotid restenosis: a double-center experience with carotid bypass
Montelione Nunzio;Stilo F;
2017-01-01
Abstract
Background: In-stent restenosis (ISR) after CAS is a relatively common complication (range 5-12%). Usually, a new endovascular intervention is proposed to treat ISR, but catheter based procedures reveal unsatisfactory long-term results, and in some cases, stent removal and carotid reconstruction are required.The aim of the present study was to review our experience with early and long-term outcomes of symptomatic patients treated for intra-stent carotid restenosis with carotid bypasses (CB).Methods: Data were retrospectively collected from a prospectively complied database on patients treated with CB in two high-volume Italian centers between 2008 and 2015, for symptomatic high-grade ISR after CAS. After carotid endarterectomy and stent removal, a greater saphenous vein (GSV) was preferentially used as the graft; when a GSV was not available, a 6mm polytetrafluoroethylene (PTFE) graft was implanted. Standard follow-up protocol in both centers included clinical examinations, duplex scans (DUS) and computed tomographic angiography (CTAs) at one month after surgery. In the absence of new clinical events, a routine duplex surveillance was scheduled at three, six and 12 months and yearly thereafter. Measures considered for analysis were perioperative (30-day) and long-term follow-up of new ipsilateral cerebral events, neurological eventsand all causes of death, and needs for reintervention. In addition, peripheral nerve palsy, cervical hematoma, and other local complications after surgery were noted.Results: The study population was comprised of 12 patients (10 men and two women; mean age 69.3 years ±10.8 years). Mean time from index CAS to stent explantation and CB was 37.7 ± 18.4 months. Surgical history of treated patients is reported in the Table. General anesthesia was performed in five (41.7%) cases; all other procedures were performed under local anesthesia (58.3%). Selective carotid shunts were required in two patients (17%). After whole stent removal, GSV grafts were employed in seven cases (58.3%) and PTFE grafts in the other five (41.7%) cases. Intraoperative neurological complication rates were null. One patient, with ISR after post-CEA restenosis, presented with a transient dysphagia. At 30-day follow-up, no new neurological complications, reinterventions or deaths occurred. At mean follow-up of 46.2±22.7 months, three patients died (two of acute myocardial infarctions and one of lung cancer), in absence of further neurological events. At DUS examinations, all CB were patents without reinterventions. One patient treated by PTFE graft developed a non-hemodynamically restenosis.Conclusions: In our experience, CB offers satisfactory results in patients treated for symptomatic ISR, with an acceptable risk of cranial nerve injuries even in patients with prior carotid surgery.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
