title: Long-term Comparative Outcomes of Carotid Artery Stenting Following Previous Carotid Endarterectomy vs De Novo Lesions.
abstract: OBJECTIVE
  To report the long-term outcomes of patients who underwent carotid artery stenting (CAS) for de novo carotid stenosis vs patients treated for restenosis after carotid endarterectomy (CEA).
  
  
  METHODS
  A retrospective review was conducted of all 385 patients (mean age 68.6±9.6 years; 231 men) who underwent 435 CAS procedures at a large tertiary care center between January 1999 and December 2013. For analysis, patients were stratified based on their lesion type [de novo (dn) vs post-CEA restenosis (res)] and subclassified by symptoms status [symptomatic (Sx) or asymptomatic (Asx)], creating 4 groups: (1) CAS-dn Asx, (2) CAS-dn Sx, (3) CAS-res Asx, and (4) CAS-res Sx. For the CAS-res group, the mean elapsed time from CEA to CAS was 72.4±63.6 months. Outcomes included target vessel reintervention (TVR) and in-stent restenosis (ISR), the latter defined by a carotid duplex ultrasound velocity >275 cm/s.
  
  
  RESULTS
  The main indication for initial carotid angiography with possible revascularization was severe carotid stenosis (≥70%-99% on duplex) in both CAS-dn and CAS-res groups (83.6% vs 83.7%, p=0.999). There were no significant differences in the percentage of patients with postintervention residual stenosis (<30%; 100% each arm) or complications between CAS-res vs CAS-dn: in-hospital stroke (1.4% vs 1.8%, respectively), myocardial infarction (0.9% vs 0%), or death (0.9% vs 0%). Mean follow-up was 62.4±45.6 months (median 53.5, range 1-180). Average clinical/TVR follow-up was greater for the CAS-res group (71.9±48.6 months) compared with 53.3±40.5 months for the CAS-dn group (p<0.001). Across the 4 study groups, there were no differences in freedom from ISR (p=0.174) or TVR (p=0.856). Multivariate analysis found peripheral vascular disease (PVD) as the sole ISR independent predictor [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.03 to 3.62, p=0.041], while significant predictors for TVR were age <65 years at the time of the procedure (HR 2.55, 95% CI 1.05 to 6.18, p=0.039) and PVD (HR 2.46, 95% CI 1.03 to 5.87, p=0.043).
  
  
  CONCLUSIONS
  The current study suggests that CAS is a feasible and durable therapeutic option for recurrent restenosis after CEA. Long-term outcomes were similar for patients treated for de novo lesions or post-CEA restenosis. Age and PVD appear to influence long-term CAS durability.
authors: Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA amousa@hsc.wvu.edu.
authors: Albeir Y
authors: AY
authors: Mousa
authors: Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA.
authors: Ali F
authors: AF
authors: AbuRahma
authors: Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA.
authors: Joseph
authors: J
authors: Bozzay
authors: Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA.
authors: Mike
authors: M
authors: Broce
authors: Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA.
authors: Maher
authors: M
authors: Kali
authors: Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA.
authors: Michael
authors: M
authors: Yacoub
authors: Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA.
authors: Patrick
authors: P
authors: Stone
authors: Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA.
authors: Mark C
authors: MC
authors: Bates
mesh_terms: D000367:Age Factors; D000368:Aged; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation*; D002340:Carotid Artery Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery / Q000628:therapy*; D015897:Comorbidity; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000453:epidemiology; D016016:Proportional Hazards Models; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014903:West Virginia
keywords: angioplasty; carotid artery stenting; carotid endarterectomy; carotid stenosis; in-stent restenosis; morbidity; mortality; myocardial infarction; outcomes; peripheral vascular disease; restenosis; stent; stroke; target vessel reintervention