Redo carotid endarterectomy versus primary carotid endarterectomy.

BACKGROUND AND PURPOSE: Several authorities have recently advocated carotid stenting for recurrent carotid stenosis because of the perception that redo surgery has a higher complication rate than primary carotid endarterectomy (CEA). This study compares the early and late results of reoperations versus primary CEA. METHODS: All reoperations for recurrent carotid stenosis performed during a recent 7-year period by a single vascular surgeon were compared with primary CEA. Because all redo CEAs were done with polytetrafluoroethylene (PTFE) or vein patch closure, we only analyzed those primary CEAs that used the same patch closures. A Kaplan-Meier life-table analysis was used to estimate stroke-free survival rates and freedom from >/=50% recurrent stenosis. RESULTS: Of 547 primary CEAs, 265 had PTFE or saphenous vein patch closure, and 124 reoperations had PTFE or vein patch closure during the same period. Both groups had similar demographic characteristics. The indications for reoperation and primary CEA were symptomatic stenosis in 78% and 58% of cases and asymptomatic >/=80% stenosis in 22% and 42% of cases, respectively (P<0.001). The 30-day perioperative stroke and transient ischemic attack rates for reoperation and primary CEA were 4.8% versus 0.8% (P=0.015) and 4% versus 1.1%, respectively, with no perioperative deaths in either group. Cranial nerve injury was noted in 17% of reoperation patients versus 5.3% of primary CEA patients; however, most of these injuries were transient (P<0.001). Mean hospital stay was 1.8 days for reoperation versus 1.6 days for primary CEA. Cumulative rates of stroke-free survival and freedom from >/=50% recurrent stenosis for reoperation and primary CEA at 1, 3, and 5 years were 96%, 91%, and 82% and 98%, 96%, and 95% versus 94%, 92%, and 91% and 98%, 96%, and 96%, respectively (no significant differences). CONCLUSIONS: Reoperation carries higher perioperative stroke and cranial nerve injury rates than primary CEA. However, reoperations are durable and have stroke-free survival rates that are similar to primary CEA. These considerations should be kept in mind when carotid stenting is recommended instead of reoperation.

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 for 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 procedures (58 reoperations, Group I, and 25 PTA/stentings, Group II) were done for RCS. Patients were followed at regular intervals with duplex ultrasound scanning. The outcome of the stented group (Group II) was divided into early experience (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 > or =50% recurrent restenosis for both groups. RESULTS: The demographic and clinical characteristics and indications for intervention were similar for both groups. The mean time from the original CEA to reoperation was 41 months in Group I versus 43 months in Group II. Overall, stenting had higher 30-day stroke rates than reoperations-16% (3 major 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 I (0% versus 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 > or =50% restenosis was higher in Group II than in Group I (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, versus 79%, 79%, 79%, and 79%, respectively, for Group II (P =.059). Freedom from recurrent > or =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 II (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/stenting has a higher incidence of restenosis than reoperation, which is associated with a percentage of cranial nerve injuries. Therefore, PTA/stenting can be an alternative to reoperation, particularly in marginal surgical risk patients.

Iliofemoral deep vein thrombosis: conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting.

OBJECTIVE: To compare conventional treatment (heparin and warfarin) of iliofemoral venous thrombosis with multimodality treatment (lysis and stenting). SUMMARY BACKGROUND DATA: Several studies have reported on conventional therapy for iliofemoral venous thrombosis with disappointing results. However, more recent studies have reported better results with multimodality treatment. METHODS: Fifty-one consecutive patients with extensive iliofemoral venous thrombosis were treated during a 10-year period. If there were no contraindications, patients were given the option to choose between conventional therapy (group 1) and multimodality therapy (group 2). The multimodality treatment strategy included catheter-directed lysis followed by percutaneous transluminal balloon angioplasty (PTA) and stenting for residual iliac stenoses. All patients underwent routine venous duplex imaging at 30 days, 3 months, 6 months, and every 6 months thereafter. RESULTS: There were 33 patients in group 1 and 18 patients in group 2. Demographic and clinical characteristics were comparable for both groups. Initial lysis was achieved in 16 of 18 patients (89%) in group 2. Ten of 18 patients in group 2 had residual stenosis after lysis (8 primary and 2 secondary to malignancy), and they were treated with PTA/stenting with an initial success rate of 90%. Two patients in group 1 (6%) had a symptomatic pulmonary embolism (none in group 2). At 30 days, venous patency and symptom resolution were achieved in 1 of 33 patients (3%) in group 1 versus 15 of 18 (83%) in group 2. Kaplan-Meier analysis showed primary iliofemoral venous patency rates at 1, 3, and 5 years of 24%, 18%, and 18% and 83%, 69%, and 69% for groups 1 and 2, respectively. Long-term symptom resolution was achieved in 10 of 33 patients (30%) in group 1 versus 14 of 18 (78%) in group 2. Kaplan-Meier life table analysis showed similar survival rates at 1, 3, and 5 years of 100%, 93%, and 85% for group 1 and 100%, 93%, and 81% for group 2. CONCLUSIONS: Lysis/stenting treatment was more effective than conventional treatment in patients with iliofemoral vein thrombosis.