Surgical management of acute complications and critical restenosis following carotid artery stenting |
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Authors: | Erik L Owens Norman H Kumins John J Bergan Steve R Sparks |
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Institution: | (1) Division of Vascular Surgery, Department of Surgery, University of California, San Diego, CA., US;(2) Section of Vascular Surgery, VA San Diego Healthcare System, San Diego, CA, US |
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Abstract: | Carotid artery angioplasty with stenting (CAS) is being increasingly used in the treatment of extracranial carotid artery
stenosis. As in other catheter-based approaches to the treatment of arterial disease, surgical intervention may be required
because of either acute complications or correct critical restenosis. We have reviewed our experience managing early complications
and critical in-stent restenoses after CAS in a tertiary care university hospital and a Veterans Affairs Medical Center. During
the last 5 years, 22 carotid arteries (21 patients) underwent CAS. One patient developed thrombosis and rupture of the carotid
artery during stenting. Two other patients (3 arteries) developed critical restenosis within 12 months. Subsequent surgical
reconstructions included an internal carotid artery (ICA)–to–external carotid artery (ECA) transposition and a common carotid
artery (CCA)–to–ICA bypass with reversed saphenous vein (RSV). The patient who underwent CCA–to–ICA bypass later required
subclavian–to–ICA bypass because of rapidly progressive intimal hyperplasia and subsequent occlusion of the CCA. The other
patient has not had surgical repair because of his deteriorating condition and significant co-morbidities. During the same
time period, two additional patients were referred from outside institutions specifically for surgical intervention after
carotid stenting. One had delayed rupture of the carotid artery 1 day after stenting and underwent urgent surgical repair.
Another patient had early, critical restenosis within the stent and underwent placement of a CCA–to–ICA interposition graft
using RSV. Acute treatment failures after CAS can be successfully managed using standard surgical techniques. Patients who
develop critical in-stent restenosis requiring surgical repair may need more challenging surgical reconstructions to maintain
cerebral perfusion. |
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