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Objectives:  Carotid artery stenting (CAS) is an alternative treatment for high risk patients with carotid disease, with recent studies reporting reasonable stroke protection and reduced myocardial infarction compared to carotid endarterectomy (CEA). However, the criteria defining restenosis and the factors predicting restenosis remain controversial.
Methods:   The records of all patients who underwent CAS at our institution between January 2006 and December 2012 were reviewed; patients with combined procedures or with stents placed in the origin of the common carotid artery were excluded. Preoperative, operative, and postoperative data was reviewed. JMP 9.0.0 software was used for data analysis.
Results:  34 patients underwent 35 CAS interventions with 38 stents [19 internal carotid artery (ICA 50%), 1 common carotid artery (CCA 3%), 18 ICA and CCA (47%)]; 29% of stents were closed cell and 71% were open cell.  All patients were male with a mean age of 70±7 years; 21 (60%) had prior ipsilateral neck surgery; 9 (26%) had a history of neck radiation; 8 (23%) reported ipsilateral stroke or transient ischemic attack (TIA) within 6 months prior to CAS. Angiographic success of CAS was 100%; perioperative mortality and cerebrovascular complications were 0% and 3% (n=1) respectively. The mean follow-up time was 37.4±24.2 months during which 6 (17%) patients underwent angioplasty with or without stenting for in-stent restenosis. Restenosis was defined using three ICA peak systolic velocity (PSV) maximum values (>250, >300, >350 cm/sec); intervention for restenosis was correlated with all 3 criteria, with 8 (23%; p=0.005), 7 (20%; p=0.0017), and 5 (14%; p=0.001) patients developing restenosis, respectively. Similarly, restenosis was also defined using three ICA/CCA PSV ratios (>3.75, >4.0, >4.25); intervention for restenosis was also correlated with all 3 of these criteria, with 8 (23%; p=0.005), 7 (20%; p=0.0017), and 6 (17%; p=0.0004) patients developing restenosis, respectively. Presence of calcification, ulceration, stent type, and preoperative maximal PSV were predictive of restenosis using univariable analysis. Multivariable analysis showed that calcification was predictive of restenosis defined by PSV >250 cm/sec (p=0.0496).
Conclusions:  CAS can be performed in a selected, high-risk population with excellent perioperative results. Development of in-stent restenosis depends on the criteria used to define it. Calcification predicts in-stent restenosis, and patients with carotid calcification may form a group needing more intense post-procedure surveillance.