Technical Strategies for Recurrent Carotid Stenosis following Angioplasty and Stenting

As the number of carotid angioplasty and stent procedures increases, vascular surgeons should anticipate the need for increased surgical correction for complications of stenting and, particularly, in-stent restenosis. This study reviews operative technique alternatives for hemodynamically significant recurrent carotid stenosis following angioplasty and stent placement. Four techniques have been used for repair of carotid in-stent restenosis. All operations were performed with continuous electroencephalographic monitoring. Stents were completely removed in two patients. Operations performed were (1) longitudinal arteriotomy through the stent with patch angioplasty, (2) common carotid to distal internal carotid artery (ICA) bypass with polytetrafluoroethylene (PTFE), (3) subclavian to distal ICA bypass with PTFE, and (4) carotid endarterectomy with complete stent removal and patch angioplasty. Mean operative time was 133 ± 22 min. Mean follow-up was 27.5 ± 29 months. There were no postoperative strokes, myocardial infarctions, or deaths. No cranial nerve injuries were noted. No patients developed postoperative neck hematomas requiring return to the operating room. All patients were stable at follow-up without evidence of recurrent stenosis on postoperative duplex ultrasound. Repair of carotid restenosis following angioplasty and stenting can be achieved with or without complete stent removal. Multiple technical approaches may be required, depending on the length and location of the lesion and stents, the presence of complete common carotid occlusion, and the degree of surrounding inflammation.