Comparative study of operative treatment and percutaneous transluminal angioplasty/stenting for recurrent carotid disease

Purpose: This study is a nonrandomized parallel comparison of the outcome f or carotid endarterectomy (CEA) and percutaneous transluminal angioplasty ( PTA)/stenting for recurrent carotid artery stenosis (RCS). Methods and Patients. Between June 1996 and June 2000, 83 carotid procedure s (58 reoperations, Group I, and 25 PTA/stentings, Group II) were done for RCS. Patients were followed at regular intervals with duplex ultrasound sca nning. The outcome of the stented group (Group II) was divided into early e xperience (Group IIA, first 12 cases) and late experience (Group IIB, last 13 cases) for learning curve consideration, and each was compared with the reoperation group. A Kaplan-Meier life table analysis was used to estimate the stroke-free survival rates and freedom from greater than or equal to 50 % recurrent restenosis for both groups. Results. The demographic and clinical characteristics and indications for i ntervention were similar for both groups. The mean time from the original C EA to reoperation was 41 months in Group I versus 43 months in Group IL Ove rall, stenting had higher 30-day stroke rates than reoperations-16% (3 majo r and 1 minor stroke) versus 3.4% (1 out of 2 [1.7%] was a major stroke, P < .05). However, Group IIB had similar major stroke rates to Group 1 (0% ve rsus 1.7%). Cranial nerve injury was noted in 10 patients (17%) in Group I (only 1 [1.7%] was permanent) versus 0% in Group II (P < .05). Recurrent gr eater than or equal to 50% restenosis was higher in Group II than in Group 1 (24% versus 0%, P < .001). Stroke-free survival rates at 6 months and 1, 2, and 3 years for Group I were 97%, 97%, 94%, and 82%, respectively, versu s 79%, 79%, 79%, and 79%, respectively, for Group II (P =.059). Freedom fro m recurrent greater than or equal to 50% restenosis rates at 6 months and 1 , 2, and 3 years were 100%, 100%, 100%, and 100%, respectively, for Group I versus 100%, 94%, 65%, and 44%, respectively, for Group Il (P < .0001). Conclusions. Carotid PTA/stenting has a similar 30-day stroke rate to that of reoperation for RCS once experience is established. However, PTA/stentin g has a higher incidence of restenosis than reoperation, which is associate d with a percentage of cranial nerve injuries. Therefore, PTA/stenting can be an alternative to reoperation, particularly in marginal surgical risk pa tients.