In-stent restenosis after carotid angioplasty and stenting: A challenge for the vascular surgeon

Purpose. This study aims to review the incidence of in-stent restenosis (ISR), the factors which determine restenosis, and to evaluate the use of various endovascular techniques for the management of ISR following carotid artery stenting (CAS). Methods. Four hundred and seven patients (334 men, mean age 63 years, range 46-86, median 65 years) were treated with CAS between December 2000 and March 2004. Three hundred and seventy-two (89 %) patients had at least one ultrasound evaluation performed 6 months after procedure (range 6-40). Recurrent stenosis > 80 % detected with duplex ultrasound scans were further evaluated by angiography and treated with repeat endovascular procedure. Results. CAS was performed successfully in all cases with a Carotid WallStent (Boston Scientific) using a cerebral protection device (filter). Perioperative complications included four (0.9 %) minor and two (0.4 %) major strokes these latter two patients died at 5 and 12 days after the operation. No other deaths occurred. A total of 15 carotid arteries (3.6 %) in 14 patients had ISR. All ISR were treated with a repeat endovascular procedure: three balloon angioplasty alone, eight angioplasty and secondary stenting, four angioplasty with cutting balloon. Postsurgical restenosis was confirmed to be the only predictive factor for the development of in-stent restenosis (OR 14.5, 95 % CI 2.3-113.4, p = 0.005). Endovascular treatment of ISR achieved technical success without periprocedurale complications and the absence of significant restenosis over a median follow up time of 12.4 months (range 3.5-30.7). Conclusion. Our experience with a large cohort of CAS showed an encouragingly low incidence of ISR (3.6 %) and successful treatment by repeat endovascular intervention. We recommend attempting all endovascular possibilities before performing stent removal.