title: In-stent recurrent stenosis after carotid artery stenting: life table analysis and clinical relevance.
abstract: OBJECTIVE
  Carotid artery stenting has been proposed as an alternative to carotid endarterectomy in cerebral revascularization. Although early results from several centers have been encouraging, concerns remain regarding long-term durability of carotid artery stenting. We report the incidence, characteristics, and management of in-stent recurrent stenosis after long-term follow-up of carotid artery stenting.
  
  
  METHODS
  Carotid artery stenting (n = 122) was performed in 118 patients between September 1996 and March 2003. Indications included recurrent stenosis after previous carotid endarterectomy (66%), primary lesions in patients at high-risk (29%), and previous ipsilateral cervical radiation therapy (5%). Fifty-five percent of patients had asymptomatic stenosis; 45% had symptomatic lesions. Each patient was followed up with serial duplex ultrasound scanning. Selective angiography and repeat intervention were performed when duplex ultrasound scans demonstrated 80% or greater in-stent recurrent stenosis. Data were prospectively recorded, and were statistically analyzed with the Kaplan-Meier method and log-rank test.
  
  
  RESULTS
  Carotid artery stenting was performed successfully in all cases, with the WallStent or Acculink carotid stent. Thirty-day stroke and death rate was 3.3%, attributable to retinal infarction (n = 1), hemispheric stroke (n = 1), and death (n = 2). Over follow-up of 1 to 74 months (mean, 18.8 months), 22 patients had in-stent recurrent stenosis (40%-59%, n = 11; 60%-79%, n = 6; > or =80%, n = 5), which occurred within 18 months of carotid artery stenting in 13 patients (60%). None of the patients with in-stent recurrent stenosis exhibited neurologic symptoms. Life table analysis and Kaplan-Meier curves predicted cumulative in-stent recurrent stenosis 80% or greater in 6.4% of patients at 60 months. Three of five in-stent recurrent stenoses occurred within 15 months of carotid artery stenting, and one each occurred at 20 and 47 months, respectively. Repeat angioplasty was performed once in 3 patients and three times in 1 patient, and repeat stenting in 1 patient, without complications. One of these patients demonstrated asymptomatic internal carotid artery occlusion 1 year after repeat intervention.
  
  
  CONCLUSIONS
  Carotid artery stenting can be performed with a low incidence of periprocedural complications. The cumulative incidence of clinically significant in-stent recurrent stenosis (> or =80%) over 5 years is low (6.4%). In-stent restenosis was not associated with neurologic symptoms in the 5 patients noted in this cohort. Most instances of in-stent recurrent stenosis occur early after carotid artery stenting, and can be managed successfully with endovascular techniques.
authors.affiliation: Division of Vascular Surgery, UMDNJ-New Jersey Medical School, 185 S. Orange Avenue, MSB-H-578, Newark, NJ 07103, USA. lalbk@umdnj.edu
authors.forename: Brajesh K
authors.initials: BK
authors.lastname: Lal
authors.forename: Robert W
authors.initials: RW
authors.lastname: Hobson
authors.forename: Jonathan
authors.initials: J
authors.lastname: Goldstein
authors.forename: Madge
authors.initials: M
authors.lastname: Geohagan
authors.forename: Elie
authors.initials: E
authors.lastname: Chakhtoura
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pappas
authors.forename: Zafar
authors.initials: Z
authors.lastname: Jamil
authors.forename: Paul B
authors.initials: PB
authors.lastname: Haser
authors.forename: Shubha
authors.initials: S
authors.lastname: Varma
authors.forename: Frank T
authors.initials: FT
authors.lastname: Padberg
authors.forename: Joaquim J
authors.initials: JJ
authors.lastname: Cerveira
mesh_terms: D000368:Aged; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D016893:Carotid Stenosis / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000453:epidemiology* / Q000209:etiology* / Q000628:therapy; D006801:Humans; D015994:Incidence; D015993:Life Tables; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015607:Stents / Q000009:adverse effects*; D013997:Time Factors