Carotid Artery Stenting for Post-Carotid Endarterectomy Restenosis is Safer than Redo Carotid Endarterectomy, and Should be the Procedure of Choice

OBJECTIVES:
Carotid artery stenting (CAS) has been advocated as an alternative to redo surgery for patients with post-carotid endarterectomy (CEA) restenosis. This study compared early and late clinical outcomes for both groups.
METHODS:
This study analyzed 192 patients: 72 had reoperation (Group A) and 120 had CAS for post-CEA stenosis (Group B). Patients were followed prospectively and had duplex ultrasounds at one month, and every 6-12 months thereafter.
RESULTS:
Demographic/clinical characteristics were comparable for both groups, except for diabetes mellitus and coronary artery disease, which were significantly higher in Group B. Indications for reoperations were transient ischemic attacks (TIA)/stroke in 72% for Group A versus 57% for Group B (p=0.0328). Mean follow-up was 33 months (range: 1-86) for Group A and 24 months (range: 1-78) for Group B (p=0.0026). The proportion of early (<24 months) CEA restenosis was 51% in Group A versus 27% in Group B (p=0.0013). Perioperative stroke rates were 3% and 1%, respectively (p=0.5573). There were no MIs or deaths in either group. Overall perioperative complication rates were 19% (including 14% cranial nerve injury [12% transient and 2% permanent]) in Group A versus 2% in Group B (p<0.0001). Combined early and late stroke rates for Groups A and B were 3% and 2%, respectively (p=0.6347). Stroke-free rates at 1, 2, 3, and 4 years for Groups A and B were 97%, 97%, 97%, and 97%; and 98%, 98%, 98%, and 98%, respectively (p=0.6490). Stroke-free survival rates were also similar. Freedom from ≥50% restenosis at 1, 2, 3, and 4 years were 98%, 95%, 95%, and 95% for Group A versus 95%, 89%, 80%, and 72% for Group B (p=0.0175). Freedom from ≥80% restenosis at 1, 2, 3, and 4 years for Groups A and B were 98%, 97%, 97%, and 97%; versus 99%, 96%, 92%, and 87%, respectively (p=0.2281). Four patients (one TIA) in Group B had reintervention for ≥80% restenosis.
CONCLUSIONS:
CAS is as effective, and perhaps safer, than redo CEA.