Bypass for symptomatic in-stent carotid restenosis

To evaluate early and long-term outcomes of symptomatic patients treated for in-stent carotid restenosis (ISR) with carotid bypass (CB).

Data were retrospectively collected from a prospectively compiled database on patients treated with CB in two high-volume Italian centers between 2008 and 2016, for symptomatic high-grade ISR after CAS. After carotid endarterectomy and stent removal, a greater saphenous vein (GSV) was preferentially employed as the graft; when the GSV was not accessible, a 6mm polytetrafluoroethylene (PTFE) graft was implanted. Standard follow-up protocol included clinical examinations, duplex scans (DUS) and computed tomographic angiography. Measures considered for analysis were perioperative (30-day) and long-term occurrence of new ipsilateral cerebral events, neurological deficits, death from all causes, and needs for reintervention. In addition, peripheral nerve palsy, cervical hematomas, and other local complications after surgery were noted.

The population of the study comprised 13 patients (11 men and two women; median age was 66.5years (range 56-88)). Mean times from index CAS to stent explantation were 38.9±18.2months. GSV grafts were used in seven cases (53.8%) and PTFE grafts in the remaining six (46.2%) cases. Intraoperative neurological complications rate was null. One patient presented a transient dysphagia. At 30-day, no new neurological complications, reinterventions or deaths occurred. At mean follow-up of 41.2±18.2months, three patients died in absence of further neurological events. None of the CB patients required reintervention.

In our experience, CB offers satisfactory results in patients treated for symptomatic ISR with an acceptable risk of cranial nerve injury.