IP117. Symptomatic Intrastent Carotid Restenosis: A Double-Center Experience With Carotid Bypass

In-stent restenosis (ISR) after carotid artery stenting (CAS) is a relatively common complication (range, 5%-12%). Usually, a new endovascular intervention is proposed to treat ISR, but catheter-based procedures reveal unsatisfactory long-term results, and in some cases, stent removal and carotid reconstruction are required. The aim of the present study was to review our experience with early and long-term outcomes of symptomatic patients treated for intrastent carotid restenosis with carotid bypasses (CB). Data were retrospectively collected from a prospectively complied database on patients treated with CB in two high-volume Italian centers between 2008 and 2015, for symptomatic high-grade ISR after CAS. After stent removal, a great saphenous vein (GSV) was preferentially used as the graft; when a GSV was not available, a 6-mm polytetrafluoroethylene (PTFE) graft was implanted. Standard follow-up protocol in both centers included clinical examinations, duplex ultrasound scans (DUS), and computed tomography angiography at 1 month after surgery. In the absence of new clinical events, a routine DUS surveillance was scheduled at 3, 6, and 12 months and yearly thereafter. Measures considered for analysis were perioperative (30-day) and long-term follow-up of new ipsilateral cerebral events, neurologic events, and all causes of death, and needs for reintervention. In addition, peripheral nerve palsy, cervical hematoma, and other local complications after surgery were noted. The study population comprised 12 patients (10 men and 2 women; mean age, 69.3 ± 10.8 years). Mean time from index CAS to stent explantation and CB was 37.7 ± 18.4 months. Surgical history of treated patients is reported in the Table. General anesthesia was performed in five cases (41.7%); all other procedures (58.3%) were performed under local anesthesia. Selective carotid shunts were required in two patients (17%). After stent removal, GSV grafts were used in seven cases (58.3%) and PTFE grafts in the other five cases (41.7%). Intraoperative neurologic complication rates were null. One patient, with ISR after post-CEA restenosis, presented with a transient dysphagia. At 30-day follow-up, no new neurologic complications, reinterventions, or deaths occurred. At mean follow-up of 46.2 ± 22.7 months, three patients died (two of acute myocardial infarctions and one of lung cancer), in the absence of further neurologic events. At DUS examinations, all CB were patents without reinterventions. One patient treated by PTFE graft developed a nonhemodynamic restenosis. In our experience, CB offers satisfactory results in patients treated for symptomatic ISR, with an acceptable risk of cranial nerve injuries even in patients with prior carotid surgery.TableSurgical history of patients treated in present seriesPatientsType of stentCAS de novoRedo after CASTime from index CAS to explant (months)1WallstentYesNo282PreciseYesNo463WallstentYesYes (stent in stent)314WallstentYesNo635WallstentNoYes (PTA)366ProtegeNoNo137WallstentYesNo748WallstentYesNo259WallstentYesYes (stent in stent)5310PreciseYesNo2511WallstentNoNo1812WallstentYesNo40CAS, Carotid artery stenting; PTA, percutaneous angioplasty. Open table in a new tab