Back to Karmody Posters

Objectives:Enthusiasm for carotid artery stenting (CAS) in both community and academic Medical Centers has resulted in a new cohort of patients requiring complicated carotid artery revascularization following failed stenting.
Methods: A retrospective review of five patients who were referred for complications of CAS. Each case was reviewed and analyzed. The difficulties in CAS involved a variety of different scenarios: including problems occurring at the time of carotid artery stenting, failure of long-term artery patency and for continuing or progressive neurologic events following carotid artery stenting.
Results:
The first patient developed a high-grade in-stent re-stenosis. The stent was placed for recurrent disease following redo carotid endarterectomy and was located 2.5 cm above a high bifurcation. Patient two was referred for in-stent re-stenosis 3.9 cm above the bifurcation. Patient three had primary stenting for an asymptomatic severe stenosis, had multiple TIAs followed by a hemispheric stroke two months after CAS and was noted to have a severe complex in-stent restenosis. Patient four developed severe extensive recurrent asymptomatic restenosis after CAS involving the common and internal carotid arteries. Patient five underwent carotid artery stenting. During completion angiography it was revealed that the patient had an anomalous takeoff of the internal carotid artery that was covered by the stent. He was having crescendo TIA's.
Operative interventions consisted of tedious carotid artery exposure with hypoglossal nerve preservation. The digastric muscle was transected in 4 cases. One patient underwent mandibular subluxation by the otolaryngology service. Three patients required intraoperative shunting. Three patients underwent enbloc resection of the internal carotid artery and reconstruction with saphenous vein interposition grafting. Two cases had stent extraction, re-endarterectomy and Dacron patch angioplasty.
Postoperatively, three patients had hypoglossal nerve paresis with full recovery within 6 months. There were no other cranial nerve injuries, no perioperative strokes and there were no other major complications. Length of stay ranged from 23 hours to 3 days. Follow-up ranged from 4 to 48 months.
Carotid duplex scans revealed no hemodynamically significant recurrences (>60%) and no patients had ischemic neurologic events in a 4 to 48 month follow-up.
Conclusions:
With an increasing number of CAS being performed, vascular surgeons can anticipate increased numbers of complicated and difficult open procedures for failed stenting. Appropriate preoperative planning is essential for good surgical outcomes.