Clinicopathologic correlation in postendarterectomy recurrent stenosis. A case report and bibliographic review

The case history of a 60-year-old man with symptomatic recurrent stenosis of the left carotid artery 20 years after carotid endarterectomy is presented. At reoperation (repeat endarterectomy and venous patch angioplasty) the lumen was found to be reduced by 60% and histopathologic study revealed atheromatosis with organizing mural thrombus. The case is discussed in the context of the recent literature concerning restenosis, the reported frequency of which varies depending on the size of the population studied and the method of follow-up, with noninvasive studies revealing that restenosis is more commonly asymptomatic than symptomatic. Early simple fibrous restenosis differs histologically from the more complex, frankly atherosclerotic late restenosis and appears to reproduce the original pathologic condition of the carotid bifurcation; as in the original lesions hemodynamic conditions probably play a major etiologic role in the formation of the restenoses. The most important clinical factor in restenosis is continued cigarette smoking. In the majority of the studies reviewed, more than half of the patients with recurrent disease presented with symptoms referable to the site of the original operation. An argument in favor of routine vein patching during the primary procedure to attempt to prevent restenosis is presented.