title: Altered in-stent hemodynamics may cause erroneous upgrading of moderate carotid artery restenosis when evaluated by duplex ultrasound.
abstract: OBJECTIVE
  To assess the influence of stent application on in-stent hemodynamics under standardized conditions.
  
  
  METHODS
  Ovine common carotid arteries before and after stent (6 × 40 mm, sinus-Carotid-RXt, combined open-closed cell design; Optimed, Ettlingen, Germany) application were used. Plastic tubes, 10 mm in length, simulating stenosis were placed in the middle of the applied stent to induce different degrees of stenosis (moderate 57.8% and severe 76.4%). Flow velocity and dynamic compliance were, respectively, measured with ultrasound and laser scan; proximal, in-stent, and distal to the stented arterial segment (1 cm proximal and distal) in a pulsatile ex vivo circulation system.
  
  
  RESULTS
  Stent insertion caused the in-stent peak systolic velocity to increase 22% without stenosis, 31% with moderate stenosis, and 23% with severe stenosis. Stent insertion without stenosis caused no significant increase in in-stent end-diastolic velocity (EDV) but a 17% increase with moderate stenosis. In severe stenosis, EDV was increased 56% proximal to the stenosis. Compliance was reduced threefold in the middle of the stented arterial segment where flow velocity was significantly increased.
  
  
  CONCLUSIONS
  With or without stenosis, stent introduction caused the in-stent peak systolic velocity to become significantly elevated compared with a nonstented area. EDV was also increased by stent insertion in the case of moderate stenosis. The stent-induced compliance reduction may be causal for the increase in flow velocity since the stent-induced flow velocity elevation appeared in the stented area with low compliance. Because of altered hemodynamics caused by stent introduction when measured by duplex ultrasound, caution is prudent in concluding that carotid artery stenting is associated with a higher restenosis rate than carotid endarterectomy. Mistakenly upgrading moderate to severe restenosis could result in unnecessary reintervention.
  
  
  CONCLUSIONS
  Clinical experience and prior studies support the supposition that restenosis after carotid artery stenting in carotid lesions displays erroneously elevated velocity when evaluated by duplex ultrasound (DUS), thus contributing to misleading interpretation of the degree of stenosis. This study, in contrast to studies of other groups, employs exactly the same conditions to measure flow with DUS in an unstented and then stented section of the carotid artery. Since DUS is the first-choice tool for carotid artery evaluation, knowledge about inexactness of the method is essential to avoid errors in treatment or follow-up decisions.
authors.affiliation: Department of Vascular and Endovascular Surgery, University of Heidelberg, Heidelberg, Germany. maani.hakimi@med.uni-heidelberg.de
authors.forename: Maani
authors.initials: M
authors.lastname: Hakimi
authors.forename: Peter
authors.initials: P
authors.lastname: Knez
authors.forename: Matthias
authors.initials: M
authors.lastname: Lippert
authors.forename: Nicolas
authors.initials: N
authors.lastname: Attigah
authors.forename: Karen
authors.initials: K
authors.lastname: Nelson
authors.forename: Tanja
authors.initials: T
authors.lastname: Laub
authors.forename: Dittmar
authors.initials: D
authors.lastname: Böckler
authors.forename: Thomas
authors.initials: T
authors.lastname: Schmitz-Rixen
authors.forename: Thomas
authors.initials: T
authors.lastname: Schmandra
mesh_terms: D000818:Animals; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery*; D003951:Diagnostic Errors; D006439:Hemodynamics; D012008:Recurrence; D012720:Severity of Illness Index; D012756:Sheep; D015607:Stents; D018616:Ultrasonography, Doppler, Duplex