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Long Term Outcomes of Carotid Angioplasty and Stenting After Previous Carotid Endarterectomy
Albeir Y. Mousa, MD, RPVI, Mike Broce, BA, Shadi Abu-Halimah, MD, Michael Yacoub, MD, Gurpreet Gill, MD, John E. Campbell, MD, Patrick A. Stone, MD, Mark C. Bates, MD, Ali F. AbuRahma, MD.
R C Byrd Health Science Center of West Virginia University, Charleston, WV, USA.
OBJECTIVES:
Repeated carotid endarterectomy (CEA) for recurrent carotid stenosis (RCS) carries a significant challenge with higher rates of complications in comparison to primary CEA. Carotid angioplasty and stenting (CAS) is considered a valid treatment modality for RCS. We investigated the outcomes of patients who underwent CAS for carotid stenosis (CS) and compared outcomes of patients who received CAS with CEA history (HCAS) to those with no prior surgical history (OCAS).
METHODS:
A retrospective review of all CAS cases performed at a large tertiary care center between January 2005 and May 2013. Outcomes included target vessel re-intervention (TVR) and in-stent restenosis (ISR) as defined by duplex velocity >275 cm/sec.
RESULTS:
A total of 206 patients with CS underwent 231 CAS interventions. Majority were male (61.2%), mean age of 69±10 years, and 25were excluded due to multiple prior surgeries. For the HCAS group, mean elapsed time from CEA was 81.6±63.4 months. Baseline characteristics of the two groups differed in female gender 47.3 vs 30.4%, history of CHF 9.9 vs 21.7%, history of stroke 1.1 vs 8.7% for HCAS vs OCAS, (all p<0.05), respectively. Indication for intervention in both groups was mainly symptomatic severe CS 84.6 vs 87% (p=0.689). No major complication difference between HCAS and OCAS for stroke (2.2 vs 6.1%), MI (1.1 vs 0%), CHF (1.1 vs 0%) or death (1.1 vs 0%), respectively. Though non-significant, ISR in the HCAS (13.2%) than OCAS group (6.1%; p=0.093) and significantly more TVR for HCAS (9.9%) than OCAS (2.6%; p=0.036). No difference in freedom from ISR, 67.8 vs 76.5% for HCAS and OCAS at 6 years(p=0.688). There was a strong trend for the difference in freedom from TVR with 87.4 vs 97.2% for HCAS and OCAS at 5 years (p=0.065). ISR independent predictors were diabetes (OR:2.5, p=0.050), PVD (OR:3.2, p=0.013), and pre-op aspirin use (OR:0.4, p=0.049), while predictors for TVR were asymptomatic indication (OR:4.4, p=0.011) and age at procedure < 65 years (OR:5.0, p=0.009).
CONCLUSIONS:
This study suggests that CAS is a feasible and durable therapeutic option for RCS after CEA. Despite more co-morbid conditions at the time of the index procedure, long-term outcomes for patients without history of CEA were similar to those with, while having less TVR and longer survival time free from TVR.
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