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 > or = 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.