Journal of Neurology

, 255:1309

High rate of restenosis after carotid artery stenting in patients with high-grade internal carotid artery stenosis

Medium-term follow-up
  • J. U. Harrer
  • R. Morschel
  • M. Mull
  • C. M. Kosinski
ORIGINAL COMMUNICATION

Abstract

Objective

Carotid endarterectomy (CEA) is the goldstandard procedure for the majority of patients with high-grade symptomatic internal carotid artery stenosis and also for specified high-grade asymptomatic stenoses; however, a proportion of patients are treated with carotid endovascular therapy. We aimed to document medium-term clinical and neurosonographical outcome after carotid artery stenting (CAS).

Methods

53 patients (mean age: 65 ± 8 years) with high-grade (≥ 70 % by means of duplex sonography) carotid artery stenosis were enrolled into the study. Nineteen patients had asymptomatic, 34 patients had symptomatic stenoses. All patients had a pre-interventional CT, Doppler and duplex sonography, and digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) prior to the procedural DSA. All patients were offered CEA as the gold-standard procedure and as an alternative to CAS. Both clinical and Duplex sonographical follow-up was obtained at day 1 and 7, month 1, month 3, month 6, month 12, and every subsequent 6 months after the procedure. Mean follow-up time was 22 ± 1.6 months (± SEM).

Results

2/53 patients suffered from stroke. A further 2 patients suffered from carotid artery occlusion shortly after CAS. The cumulative rate of restenosis during follow-up was 24.5 % (13/53). Four of these (7.5 %) were of high-grade and led to further interventional or surgical therapy.

Conclusions

A high rate of restenosis was found during follow-up after CAS. Our analysis of non-selected patients emphasizes that CEA remains the gold-standard procedure for the treatment of symptomatic internal carotid artery stenosis. The frequently performed endovascular treatment of carotid stenosis outside the setting of a randomized controlled trial is not supported by our data.

Key words

stroke carotid artery stenosis interventional neuroradiology carotid artery stenting 

References

  1. 1.
    ACAS investigators (1994) Clinical advisory: carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. Stroke 25:2523–2524Google Scholar
  2. 2.
    Bonvini RF, Righini M (2007) Endarterectomy versus stenting for carotid stenosis. N Engl J Med 18:305; author reply 306–307CrossRefGoogle Scholar
  3. 3.
    Carballo RE, Towne JB, Seabrook GR, Freischlag JA, Cambria RA (1996) An outcome analysis of carotid endarterectomy: the incidence and natural history of recurrent stenosis. J Vasc Surg 23:749–753PubMedCrossRefGoogle Scholar
  4. 4.
    Coward LJ, Featherstone RL, Brown MM (2005) Safety and efficacy of endovascular treatment of carotid artery stenosis compared with carotid endarterectomy: a Cochrane systematic review of the randomized evidence. Stroke 36:905–911PubMedCrossRefGoogle Scholar
  5. 5.
    Gable DR, Bergamini T, Garrett WV, Hise J, Smith BL, Shutze WP, Pearl G, Grimsley BR (2003) Intermediate follow- up of carotid artery stent placement. Am J Surg 185:183–187PubMedCrossRefGoogle Scholar
  6. 6.
    Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 363:1491–1502PubMedCrossRefGoogle Scholar
  7. 7.
    Harrison JD, Solomon MJ, Young JM, Meagher A, Hruby G, Salkeld G, Clarke S (2007) Surgical and oncology trials for rectal cancer: who will participate? Surgery 142:94–101PubMedCrossRefGoogle Scholar
  8. 8.
    Kern R, Ringleb PA, Hacke W, Mas JL, Hennerici MG (2007) Stenting for carotid artery stenosis. Nat Clin Pract Neurol 3:212–220PubMedCrossRefGoogle Scholar
  9. 9.
    Lal BK, Hobson RW 2nd, Goldstein J, Chakhtoura EY, Duran WN (2004) Carotid artery stenting: is there a need to revise ultrasound velocity criteria? J Vasc Surg 39:58–66PubMedCrossRefGoogle Scholar
  10. 10.
    Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, Larrue V, Lievre M, Leys D, Bonneville JF, Watelet J, Pruvo JP, Albucher JF, Viguier A, Piquet P, Garnier P, Viader F, Touze E, Giroud M, Hosseini H, Pillet JC, Favrole P, Neau JP, Ducrocq X; EVA- 3S Investigators (2006) Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis N Engl J Med 355:1660–1671PubMedCrossRefGoogle Scholar
  11. 11.
    Mas JL, Chatellier G, EVA-3S Investigators (2007) Corresponence on Endarterectomy versus stenting for carotid stenosis N Engl J Med 356:305–307CrossRefGoogle Scholar
  12. 12.
    McCabe DJ, Pereira AC, Clifton A, Bland JM, Brown MM; CAVATAS Investigators (2005) Restenosis after carotid angioplasty, stenting, or endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS). Stroke 36:281–286PubMedCrossRefGoogle Scholar
  13. 13.
    Meschia JF, Brott TG, Hobson RW 2nd (2007) Diagnosis and invasive management of carotid atherosclerotic stenosis. Mayo Clin Proc 82:851–858PubMedGoogle Scholar
  14. 14.
    Moore WS, Kempczinski RF, Nelson JJ, Toole JF (1998) Recurrent carotid stenosis: results of the asymptomatic carotid atherosclerosis study. Stroke 29:2018–2025PubMedGoogle Scholar
  15. 15.
    Müller KM, Schmitz F (2004) Morphological findings after stent implantation in the carotid artery. Pathologe 25:108–115PubMedCrossRefGoogle Scholar
  16. 16.
    Naylor AR (2007) What is the current status of angioplasty vs endarterectomy in patients with asymptomatic carotid artery disease. J Cardiovasc Surg 48:161–180Google Scholar
  17. 17.
    Paciaroni M, Eliasziw M, Kappelle LJ, Finan JW, Ferguson GG, Barnett HJ (1999) Medical complications associated with carotid endarterectomy. North American Symptomatic Carotid Endarterectomy Trial (NASCET). Stroke 30:1759–1763PubMedGoogle Scholar
  18. 18.
    Paciaroni M, Eliasziw M, Sharpe BL, Kappelle LJ, Chaturvedi S, Meldrum H, Barnett HJ (2000) Long-term clinical and angiographic outcomes in symptomatic patients with 70 % to 99 % carotid artery stenosis. Stroke 31:2037–2042PubMedGoogle Scholar
  19. 19.
    Poppert H, Wolf O, Resch M, Theiss W, Schmidt-Thieme T, Graefin von Einsiedel H, Heider P, Martinoff S, Sander D (2004) Differences in number, size and location of intracranial microembolic lesions after surgical versus endovascular treatment without protection device of carotid artery stenosis. J Neurol 251:1198–1203PubMedCrossRefGoogle Scholar
  20. 20.
    Rothwell PM, Gutnikov SA, Warlow CP; European Carotid Surgery Trialist‘s Collaboration (2003) Reanalysis of the final results of the European Carotid Surgery Trial. Stroke 34:514–523PubMedCrossRefGoogle Scholar
  21. 21.
    Sitzer M (2006) Atherosclerotic carotid stenosis and occlusion. Front Neurol Neurosci 21:36–56PubMedCrossRefGoogle Scholar
  22. 22.
    SPACE Collaborative Group, Ringleb PA, Allenberg J, Bruckmann H, Eckstein HH, Fraedrich G, Hartmann M, Hennerici M, Jansen O, Klein G, Kunze A, Marx P, Niederkorn K, Schmiedt W, Solymosi L, Stingele R, Zeumer H, Hacke W (2006) 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 368:1239–1247Google Scholar
  23. 23.
    Topakian R, Strasak AM, Sonnberger M, Haring HP, Nussbaumer K, Trenkler J, Aichner FT (2007) Timing of stenting of symptomatic carotid stenosis is predictive of 30-day outcome. Eur J Neurol 14:672–678PubMedCrossRefGoogle Scholar
  24. 24.
    Widder B, von Reutern GM, Neuerburg- Heusler D (1986) Morphologic and Doppler sonographic criteria for determining the degree of stenosis of the internal carotid artery. Ultraschall Med 7:70–75PubMedCrossRefGoogle Scholar
  25. 25.
    Willfort-Ehringer A, Ahmadi R, Gessl A, Gschwandtner ME, Haumer A, Lang W, Minar E, Zehetmayer S, Ehringer H (2004) Neointimal proliferation within carotid stents is more pronounced in diabetic patients with initial poor glycaemic state. J Vasc Surg 39:728–734PubMedCrossRefGoogle Scholar
  26. 26.
    Witt K, Borsch K, Daniels C, Walluscheck K, Alfke K, Jansen O, Czech N, Deuschl G, Stingele R (2007) Neuropsychological consequences of endarterectomy and endovascular angioplasty with stent placement for treatment of symptomatic carotid stenosis: A prospective randomised study. J Neurol 254:1524–1532PubMedCrossRefGoogle Scholar
  27. 27.
    Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K (2004) Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351:1493–1501PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2008

Authors and Affiliations

  • J. U. Harrer
    • 1
  • R. Morschel
    • 1
  • M. Mull
    • 2
  • C. M. Kosinski
    • 1
  1. 1.Neurological ClinicRWTH Aachen University HospitalAachenGermany
  2. 2.Dept. of NeuroradiologyRWTH Aachen University HospitalAachenGermany

Personalised recommendations