title: Carotid artery stenting outcomes are equivalent to carotid endarterectomy outcomes for patients with post-carotid endarterectomy stenosis.
abstract: BACKGROUND
  Carotid artery stenting (CAS) has been advocated as an alternative to redo surgery for patients with post-carotid endarterectomy (CEA) stenosis. This study compares early and late clinical outcomes for both groups.
  
  
  METHODS
  This study analyzes 192 patients: 72 had reoperation (Group A) and 120 had CAS for post-CEA stenosis (Group B). Patients were followed prospectively and had duplex ultrasounds at 1 month, and every 6 to 12 months thereafter. The perioperative complications (perioperative stroke, myocardial infarction/death, cranial nerve injury) and 4-year end points were analyzed. A Kaplan-Meier lifetable analysis was used to estimate rates of freedom from stroke, stroke-free survival, ≥50% restenosis, and ≥80% restenosis.
  
  
  RESULTS
  Demographic/clinical characteristics were comparable for both groups, except for diabetes mellitus and coronary artery disease, which were significantly higher in Group B. The indications for reoperations were transient ischemic attacks/stroke in 72% for Group A versus 57% for Group B (P=.0328). The mean follow-up was 33 months (range, 1-86 months) for Group A and 24 months (range, 1-78 months) for Group B (P=.0026). The proportion of early (<24 months) carotid restenosis prior to intervention was 51% in Group A versus 27% in Group B (P=.0013). The perioperative stroke rates were 3% and 1%, respectively (P=.5573). There were no myocardial infarctions or deaths in either group. The overall incidence of cranial nerve injury was 14% for Group A versus 0% for Group B (P<.0001). However, there was no statistical difference between the groups relating to permanent cranial nerve injury (1% versus 0%). The combined early and late stroke rates for Groups A and B were 3% and 2%, respectively (P=.6347). The stroke-free rates at 1, 2, 3, and 4 years for Groups A and B were 97%, 97%, 97%, and 97% and 98%, 98%, 98%, and 98%, respectively (P=.6490). The stroke-free survival rates were not significantly different. The rates of freedom from ≥50% restenosis at 1, 2, 3, and 4 years were 98%, 95%, 95%, and 95% for Group A versus 95%, 89%, 80%, and 72% for Group B (P=.0175). The freedom from ≥80% restenosis at 1, 2, 3, and 4 years for Groups A and B were 98%, 97%, 97%, and 97% versus 99%, 96%, 92%, and 87%, respectively (P=.2281). Four patients (one symptomatic) in Group B had reintervention for ≥80% restenosis. The rate of freedom from reintervention for Groups A and B were 100%, 100%, 100%, and 100% versus 94%, 89%, 83%, and 79%, respectively (P=.0634).
  
  
  CONCLUSIONS
  CAS is as safe as redo CEA. Redo CEA has a higher incidence of transient cranial nerve injury; however, CAS has a higher incidence of ≥50% in-stent restenosis.
authors.affiliation: Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV 25304, USA. ali.aburahma@camc.org
authors.forename: Ali F
authors.initials: AF
authors.lastname: AbuRahma
authors.forename: Shadi
authors.initials: S
authors.lastname: Abu-Halimah
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Hass
authors.forename: Aravinda
authors.initials: A
authors.lastname: Nanjundappa
authors.forename: Patrick A
authors.initials: PA
authors.lastname: Stone
authors.forename: Albeir
authors.initials: A
authors.lastname: Mousa
authors.forename: Erik
authors.initials: E
authors.lastname: Lough
authors.forename: L S
authors.initials: LS
authors.lastname: Dean
mesh_terms: D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016009:Chi-Square Distribution; D020209:Cranial Nerve Injuries / Q000209:etiology; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D009203:Myocardial Infarction / Q000209:etiology; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014903:West Virginia