title: Endarterectomy versus stenting in patients with prior ipsilateral carotid artery stenting.
abstract: In-stent restenosis is a recognized complication of carotid angioplasty and stenting (CAS), and it is associated with an increased risk of stroke. Few case series have reported outcomes separately following carotid endarterectomy (CEA) and CAS for the treatment of in-stent restenosis. In this study, we perform an evaluation of redo-CAS vs CEA in a large contemporary cohort of patients who underwent prior ipsilateral CAS.
  
  
  
  We studied all patients in the Vascular Quality Initiative (VQI) database, who underwent CEA or CAS between January 1, 2003, and April 30, 2016, after prior ipsilateral CAS. Univariate methods (χ2, t-test), Kaplan-Meier, logistic, and Cox regression analyses adjusting for patient characteristics were employed to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days and up to 1 year following the procedure.
  
  
  
  There were 645 carotid interventions (CEA, 134 [21%] and redo-CAS, 511 [79%]) performed in this cohort of patients with prior ipsilateral CAS. Postoperative stroke within 30 days comparing CEA vs CAS was 0% vs 0.3% (P = .61) for asymptomatic patients and 4.4% vs 3.5% (P = .79) for symptomatic patients for an overall stroke rate of 1.5% vs 1.4%. MI was 2.3% vs 1.2% (P = .35), 30-day mortality was 3.7% vs 0.9% (P = .02) following CEA vs CAS, whereas the composite of perioperative stroke/death was 4.5% vs 1.9% (P = .09). Freedom from stroke/death at 1 year was 91% for CEA and 92% for redo-CAS (P = .76). After risk adjustment, there was no significant difference in 30-day stroke (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.15-4.48; P = .82), mortality (OR, 2.21; 95% CI, 0.54-9.11; P = .27), or stroke/death (OR, 0.99; 95% CI, 0.26-3.84; P = .99) as well as 1-year stroke (hazard ratio [HR], 0.60; 95% CI, 0.13-2.85; P = .52), mortality (HR, 0.83; 95% CI, 0.42-1.65; P = .60), or stroke/death (HR, 0.80; 95% CI, 0.43-1.49; P = .48) comparing CEA with CAS. The significant predictors of perioperative stroke/death were older age, diabetes, active smoking, and preoperative American Society of Anesthesiologists class IV status (all P < .05).
  
  
  
  We have reported adverse event rates for CEA and CAS after prior CAS and shown no significant difference in perioperative and 1-year outcomes between both groups. However, CEA is offered to patients who are more severely ill than redo-CAS, resulting in significantly higher absolute mortality. We recommend avoidance of CEA especially in asymptomatic patients with serious systemic disease. Tight management of diabetes and smoking cessation remain potent targets for outcomes improvement in redo-CAS patients.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md; Division of Vascular Surgery, University of South Florida, Tampa, Fla.
authors.forename: Isibor J
authors.initials: IJ
authors.lastname: Arhuidese
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Besma
authors.initials: B
authors.lastname: Nejim
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Susruth
authors.initials: S
authors.lastname: Chavali
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Satinderjit
authors.initials: S
authors.lastname: Locham
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Tammam
authors.initials: T
authors.lastname: Obeid
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
mesh_terms: D000368:Aged; 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; D016208:Databases, Factual; D018572:Disease-Free Survival; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D016016:Proportional Hazards Models; D012008:Recurrence; D019233:Retreatment; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome