Does the type of carotid artery closure influence the management of recurrent carotid artery stenosis? Results of a 6-year prospective comparative study

Objective The purpose of the study was to evaluate the results of reoperative surgery and carotid artery stenting (CAS) in cases of recurrent carotid artery stenosis (RCS) and to compare the results of all RCS (reoperative surgery + CAS) with primary carotid endarterectomy (CEA) performed during the study period. Summary Background Data Consensus has not yet been established on the best treatment for RCS. Recently CAS has emerged as a potential alternative to carotid endarterectomy. Methods A 6-year (Jan 2000-Dec 2005) prospective study was performed. Eligible patients were those with symptomatic or asymptomatic RCS ≥80% at a preoperative angiography or angio-computed tomography. The carotid plaques were classified at a preoperative ultrasonographic scan, according to the five type classification proposed by Geroulakos (Br J Surg 1993;80:1274-7). Patients with type 1 and 2 carotid plaque were not considered for CAS. Results 56 patients were enrolled. Fifteen patients with a type 1-2 plaque underwent reoperative surgery, 41 with type 3-4 plaque underwent CAS. In 90.6% of primary closure a type 3-4 carotid plaque was found; a type 1-2 was observed in 84.5% of the polytetrafluoroethylene patch closure group. No statistical difference for the 30-day and the 6 year stroke-free rate was observed; similarly no differences emerged between all RCS (reoperative surgery + CAS) performed and primary CEA. Conclusions CAS is an acceptable alternative to surgery in the management of RCS. An accurate patient selection is required. Restenosis after CEA and direct closure is mostly associated with fibrous material. In these cases CAS might be the best choice. Randomized trials have shown that carotid endarterectomy (CEA) is the criterion standard to reduce stroke in symptomatic and asymptomatic patients with significant carotid stenosis. [1] and [2] The management of recurrent carotid stenosis (RCS) after CEA is still controversial because of the more benign nature of these lesions and the higher complication rate reported for reoperative surgery. [3], [4], [5], [6], [7] and [8] Reoperative surgery is generally recommended for asymptomatic stenosis >80% and for significant carotid restenosis in symptomatic patients. [3], [4], [5], [6], [7] and [8] Recently carotid artery stenting (CAS) has emerged as a potential alternative to CEA. This procedure has been advocated by many authors as the treatment of choice for RCS because it is perceived that reoperative surgery carries higher perioperative stroke rates and cranial nerve injury rates than primary CEA. [9] and [10] Few studies compare the results of CEA with CAS regarding RCS; inclusion criteria for CAS in these series did not pay any attention to the morphology of the carotid plaque. [11], [12] and [13] Different studies evaluated the relationship between the ecomorphology of the plaque and the histologic components; they also showed that a low echogenicity of the carotid plaque is associated with an increased risk of embolism during CAS. [14], [15] and [16] The purpose of this prospective comparative study was to evaluate the results of reoperative surgery and CAS in cases of RCS in which the treatment selection was decided on the basis of the echogenicity of the carotid plaque and to compare the stroke-free rate of all RCS (reoperative surgery + CAS) and of primary CEA performed during the study period.