TRANSLUMINAL ANGIOPLASTY FOR RECURRENT STENOSIS AFTER CAROTID ENDARTERECTOMY - PROGNOSTIC FACTORS AND INDICATIONS

Over a 15-month period ending in July 1992, 9 patients (7 male, 2 fema le; mean age 67 years) with recurrent stenosis of the internal carotid artery underwent transluminal angioplasty (TLA). The mean interval be tween endarterectomy and treatment of recurrent stenosis was 45 months (range: 9 to 84 months). All patients were symptomatic except one wit h extensive bilateral carotid dysplasia. Three patients had recurrence proximal to the endarterectomized segment (Group I); in one of these patients the narrowing was extensive. The other 6 patients (Group II) demonstrated stenoses distally. In one of these latter patients, the n arrowing developed in a vein bypass. Balloon dilation was performed by the surgical route in 3 patients and percutaneously in the other 6. P erioperative transcranial Doppler (TCD) monitoring was employed in all procedures. Postoperative treatment consisted of oral Ticlopicine. In Group I (proximal recurrence), immediate complications included one c ase of reversible spasm and two dissections that led to acute thrombos is treated by emergency bypass and to sylvian artery embolism complica ted by transient hemiplegia. In Group II (distal disease), dissection was not encountered, and only one case of transient neurologic manifes tations due to cerebral edema following reperfusion was observed. Mean follow-up has been 18 months (range: 9 to 24 months). All patients ar e presently asymptomatic. In Group II, 2 patients presented with secon dary recurrence at 6 months and were treated again by angioplasty. In one of these cases, a Palmaz stent was placed to prevent restenosis by elastic recoil. Angiography at 15 months and ultrasonography at 18 mo nths in this patient showed no signs of hyperplastic narrowing of the stent. In conclusion, TLA offers an effective alternative to surgery f or well-selected cases of recurrent stenosis after carotid endarterect omy. The lesion most amenable to TLA appears to be a hyperplastic or f ibrotic. recurrence located in the distal artery. Proximal stenosis, e specially if it is extensive, may be associated with a higher risk of dissection and subsequent neurologic complications.