CAS Compared to Redo CEA After Previous Ipsilateral Carotid Endarterectomy


December 22, 2016—In the Journal of Vascular Surgery (JVS), Isibor Arhuidese, MD, et al published findings from a population-based evaluation of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) in a large contemporary cohort of patients with carotid artery restenosis after previous ipsilateral CEA (2017;65:1–11).

According to the investigators, the background of the study is that restenosis after CEA is associated with an increased risk of stroke, and the management of critical or symptomatic restenotic lesions poses a treatment challenge. They stated that the superiority of CEA versus CAS for restenosis remains debatable because existing studies are few and limited by small sample size or the inability to align interventions with ipsilateral events beyond the periprocedural period.

In this study, the investigators found that CEA was associated with higher mortality at 30 days and at 1 year. However, there were no differences in postoperative stroke, myocardial infarction (MI), stroke/death, and stroke/death/MI between CEA and CAS after adjusting for patient characteristics. Freedom from stroke at 1 year was also similar. 

The investigators concluded that this population-based study shows higher mortality but similar stroke and MI associated with redo CEA compared with CAS after previous ipsilateral CEA. They recommend avoidance of redo CEA in very sick patients. Smoking cessation remains a potent target for improvement of outcomes of carotid revascularization in these patients, advised the investigators in JVS.

As summarized in JVS, the investigators studied all patients in the Vascular Quality Initiative database who underwent CEA or CAS after previous ipsilateral CEA between January 2003 and April 2015. They used univariate methods (χ2 and t-test) to compare patients' characteristics and outcomes at ≤ 30 days and up to 1 year. They used multivariate logistic and Cox regression analyses, adjusting for patients' demographic and clinical characteristics, to compare the procedures with respect to ipsilateral stroke, death, MI, stroke/death, and stroke/death/MI.

This cohort of patients with previous ipsilateral CEA underwent 2,863 carotid interventions: 1,047 CEA (37%) and 1,816 CAS (63%). Characteristics were similar in both groups. 

The 30-day ipsilateral stroke rates comparing CEA and CAS were 2.2% versus 1.3% for asymptomatic patients (P = .09)  and 1.2% versus 1.6% for symptomatic patients (P = .604). The 30-day mortality rates were 1.3% versus 0.6% (P = .04). The MI rates were 1.4% in CEA patients versus 1.1% in CAS patients (P = .443). Cranial nerve injury occurred in 4.1% of the redo CEA cases, and access site complications occurred in 5.3% of the CAS cases, reported the investigators in JVS.


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