Risk factors for restenosis after carotid artery angioplasty and stenting

Objectives. With carotid artery stenting (CAS) becoming an ever-increasing procedure, we sought to determine risk factors for in-stent restenosis after CAS. Methods:. Consecutive patients undergoing CAS between January 2002 and October 2004 at a tertiary care hospital were retrospectively reviewed. Patient, filter, and stent selection were left to the discretion of the attending surgeon. High-risk patients were defined by significant comorbidities or a hostile neck (prior surgery or radiation, or both), and risk factor analysis was performed. In-stent restenosis was defined as > 60%, and selective angiography was performed on patients with an in-stent restenosis > 80% by duplex ultrasound imaging. Results. Reviewed were 101 patients (55 men, 46 women) who underwent 109 CAS procedures. Comorbidities were typical for patients with atherosclerosis. In addition, 38% (n=41) of procedures were performed in patients who had prior neck surgery, of which 29% (n=32) had previous ipsilateral carotid endarterectomy. Seventeen patients (16%) had a history of neck cancer, and all had prior neck radiation. Median follow-up was 5 months (range, 0 to 30 months). Neurologic complications included three transient ischemic attacks (2.8%) and one nondisabling stroke (0.9%). There were two myocardial infarctions (1.9%) and no periprocedural deaths (30 days), for a combined stroke, myocardial infarction, and death rate of 2.9%. Asymptomatic in-stent restenosis developed in 12 carotids (11%), five of which required endovascular intervention, with a mean of 6 months to restenosis. Univariate Cox proportional hazard regression models were used to determine risk factors for the development of restenosis. Prior stroke, transient ischemic attack, amaurosis fugax, and prior neck cancer were all significant risk factors. When these significant risk factors from univariate analysis were put into multivariate analysis, however, the only marginally significant risk factor was prior neck cancer (P=.06). Kaplan-Meier analysis revealed a cumulative freedom from in-stent restenosis at 24 months of 88% 6% in patients without neck cancer compared with 27%+/- 17% (P=.02) in patients with neck cancer. Conclusions. CAS has been shown to be safe and effective in high-risk patients, with minimal adverse events.