Restenosis after prior carotid endarterectomy or carotid angioplasty and stenting: a challenging clinical entity

Both carotid endarterectomy (CEA) and carotid artery angioplasty and stenting (CAS) are used for the treatment of carotid artery disease, with advocates of both procedures claiming excellent long term stroke-free survival. While long-term patency rates for both of these procedures are generally favorable, studies have documented a restenosis rate of 1.8-11% in patients undergoing CEA and 3-31% in patients undergoing CAS, with restenotic lesions showing features of neointimal hyperplasia rather than complex atherosclerosis. The high variability in rates of restenosis are further complicated by a lack of consensus on the precise definition of restenosis as well as the optimal imaging modality that should be used to follow these patients. In the present review, we discuss the pathophysiology underlying restenosis after vascular interventions, describe the imaging modalities available and criteria used to diagnose restenosis and present the results from contemporary series of redo-CEA and CAS to treat this increasingly common clinical phenomenon.