title: Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy.
abstract: BACKGROUND
  Outcomes for patients undergoing intervention for restenosis after prior ipsilateral carotid endarterectomy (CEA) in the era of carotid angioplasty and stenting (CAS) are unclear. We compared perioperative results and durability of CAS vs CEA in patients with symptomatic or asymptomatic restenosis after prior CEA and investigated the risk of reintervention compared with primary procedures.
  
  
  METHODS
  Patients undergoing CAS and CEA for restenosis between January 2003 and March 2012 were identified within the Vascular Study Group of New England (VSGNE) database. End points included any stroke, death or myocardial infarction (MI) within 30 days, cranial nerve injury at discharge, and restenosis ≥ 70% at 1-year follow-up. Multivariable logistic regression was done to identify whether prior ipsilateral CEA was an independent predictor for adverse outcome.
  
  
  RESULTS
  Out of 9305 CEA procedures, 212 patients (2.3%) underwent redo CEA (36% symptomatic). Of 663 CAS procedures, 220 patients (33%) underwent CAS after prior ipsilateral CEA (31% symptomatic). Demographics of patients undergoing redo CEA were comparable to patients undergoing CAS after prior CEA. Stroke/death/MI rates were statistically similar between redo CEA vs CAS after prior CEA in both asymptomatic (4.4% vs 3.3%; P = .8) and symptomatic patients (6.6% vs 5.8%; P = 1.0). No significant difference in restenosis ≥ 70% was identified between redo CEA and CAS after prior CEA (5.2% vs 3.0%; P = .5). Redo CEA vs primary CEA had increased stroke/death/MI rate in both symptomatic (6.6% vs 2.3%; P = .05) and asymptomatic patients 4.4% vs 1.7%; P = .03). Prior ipsilateral CEA was an independent predictor for stroke/death/MI among all patients undergoing CEA (odds ratio, 2.1; 95% confidence interval, 1.3-3.5). No difference in cranial nerve injury was identified between redo CEA and primary CEA (5.2% vs 4.7%; P = .8).
  
  
  CONCLUSIONS
  In the VSGNE, CEA and CAS showed statistically equivalent outcomes in asymptomatic and symptomatic patients treated for restenosis after prior ipsilateral CEA. However, regardless of symptom status, the risk of reintervention was increased compared with patients undergoing primary CEA.
authors: Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors: Margriet
authors: M
authors: Fokkema
authors: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors: Gert Jan
authors: GJ
authors: de Borst
authors: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors: Brian W
authors: BW
authors: Nolan
authors: Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors: Ruby C
authors: RC
authors: Lo
authors: Department of Vascular Surgery, Eastern Maine Medical Center, Bangor, Me.
authors: Robert A
authors: RA
authors: Cambria
authors: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors: Richard J
authors: RJ
authors: Powell
authors: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors: Frans L
authors: FL
authors: Moll
authors: Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address: mscherme@bidmc.harvard.edu.
authors: Marc L
authors: ML
authors: Schermerhorn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality / Q000592:standards; D058070:Asymptomatic Diseases; D002340:Carotid Artery Diseases / Q000150:complications / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology; D009511:New England; D016017:Odds Ratio; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012008:Recurrence; D012042:Registries; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome
references: J Vasc Surg. 2008 Nov;48(5):1139-45
references: 18586446
references: J Vasc Surg. 2010 May;51(5):1124-32
references: 20303694
references: Surgery. 1992 Oct;112(4):656-61; discussion 662-3
references: 1411935
references: J Vasc Surg. 2012 Oct;56(4):990-6
references: 22579135
references: Lancet Neurol. 2013 Feb;12(2):130
references: 23151440
references: J Vasc Surg. 2001 May;33(5):1008-14
references: 11331842
references: Stroke. 2011 Apr;42(4):965-71
references: 21350208
references: J Vasc Surg. 2001 Nov;34(5):831-8
references: 11700483
references: J Vasc Surg. 2007 Dec;46(6):1093-1101; discussion 1101-2
references: 17950568
references: J Vasc Surg. 2010 May;51(5):1116-23
references: 20347551
references: J Vasc Surg. 2009 Nov;50(5):1031-9
references: 19703753
references: Ann Vasc Surg. 2003 Nov;17(6):622-8
references: 14569433
references: Ann Surg. 1985 Jul;202(1):28-35
references: 4015210
references: J Vasc Surg. 2010 Oct;52(4):897-904, 905.e1-2; discussion 904-5
references: 20620001
references: Ann Vasc Surg. 2010 Feb;24(2):190-5
references: 19748764
references: J Am Coll Cardiol. 2011 Feb 22;57(8):e16-94
references: 21288679
references: J Vasc Surg. 1999 Jul;30(1):26-35
references: 10394151
references: Stroke. 2008 Mar;39(3):1029-32
references: 18258835
references: J Vasc Surg. 2008 Feb;47(2):363-71
references: 18155873
references: N Engl J Med. 2004 Oct 7;351(15):1493-501
references: 15470212
references: N Engl J Med. 2008 Apr 10;358(15):1572-9
references: 18403765
references: J Vasc Surg. 2013 May;57(5):1318-24
references: 23406712
references: J Vasc Surg. 2003 Jun;37(6):1234-9
references: 12764270
references: J Vasc Surg. 2003 Jan;37(1):40-6
references: 12514576
references: J Vasc Surg. 1999 Jan;29(1):72-80; discussion 80-1
references: 9882791
references: J Endovasc Ther. 2013 Feb;20(1):48-60
references: 23391083
references: Lancet Neurol. 2012 Sep;11(9):755-63
references: 22857850
references: J Vasc Surg. 1996 Aug;24(2):207-12
references: 8752030
references: J Vasc Surg. 2005 Jun;41(6):942-9
references: 15944590
references: J Vasc Surg. 1999 Feb;29(2):228-35; discussion 235-8
references: 9950981
references: J Vasc Surg. 2001 Jul;34(1):5-12
references: 11436067
references: Stroke. 2001 Dec 1;32(12):2787-92
references: 11739974
references: J Neurosurg. 1994 May;80(5):781-7
references: 8169615
references: Ann Surg. 1995 May;221(5):517-21; discussion 521-4
references: 7748033
references: J Vasc Surg. 2004 May;39(5):958-65; discussion 965-6
references: 15111844
references: Semin Vasc Surg. 2007 Dec;20(4):259-66
references: 18082843
references: J Vasc Surg. 2000 Oct;32(4):649-54
references: 11013026
references: J Vasc Surg. 2008 Jan;47(1):63-73
references: 18178455
references: J Vasc Surg. 2004 Jan;39(1):155-61
references: 14718833
references: J Vasc Surg. 2010 Nov;52(5):1180-7
references: 20692794