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Stenting Versus Endarterectomy for Restenosis Following Prior Ipsilateral Carotid Endarterectomy: An Individual Patient Data Meta-analysis

Fokkema, Margriet MD*,†; Vrijenhoek, Joyce E. P. MD*,‡,§; Den Ruijter, Hester M. PhD‡,¶; Groenwold, Rolf H. H. MD, PhD; Schermerhorn, Marc L. MD; Bots, Michiel L. MD, PhD; Pasterkamp, Gerard MD, PhD; Moll, Frans L. MD, PhD*; De Borst, Gert Jan MD, PhD*the TREAT CARE Study Group

doi: 10.1097/SLA.0000000000000799
Original Articles

Objective: To study perioperative results and restenosis during follow-up of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for restenosis after prior ipsilateral CEA in an individual patient data (IPD) meta-analysis.

Background: The optimal treatment strategy for patients with restenosis after CEA remains unknown.

Methods: A comprehensive search of electronic databases (Medline, Embase) until July 1, 2013, was performed, supplemented by a review of references. Studies were considered for inclusion if they reported procedural outcome of CAS or CEA after prior ipsilateral CEA of a minimum of 5 patients. IPD were combined into 1 data set and an IPD meta-analysis was performed. The primary endpoint was perioperative stroke or death and the secondary endpoint was restenosis greater than 50% during follow-up, comparing CAS and CEA.

Results: In total, 13 studies were included, contributing to 1132 unique patients treated by CAS (10 studies, n = 653) or CEA (7 studies; n = 479). Among CAS and CEA patients, 30% versus 40% were symptomatic, respectively (P < 0.01). After adjusting for potential confounders, the primary endpoint did not differ between CAS and CEA groups (2.3% vs 2.7%, adjusted odds ratio 0.8, 95% confidence interval (CI): 0.4–1.8). Also, the risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio 1.4, 95% (CI): 0.9–2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was in 5% associated with other procedural related complications.

Conclusions: In patients with restenosis after CEA, CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up. Still, the risk of CNI and other procedure-related complications should be taken into account.

This individual patient data meta-analysis assessed the outcome in patients with restenosis after previous ipsilateral CEA, comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA). CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up.

*Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands

Department of Vascular and Endovascular Surgery, Beth Israel Medical Center, Boston, MA

Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, the Netherlands

§Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands; and

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands.

Reprints: Gert Jan de Borst, MD, PhD, University Medical Center Utrecht, Department of Vascular Surgery, G04.129, PO Box 85500, 3508 GA, Utrecht, the Netherlands. E-mail:

Margriet Fokkema and Joyce E. P. Vrijenhoek contributed equally to this manuscript.

Disclosure: Marc Schermerhorn is a consultant for Medtronic and Endologix. Jan Albert Vos has received institutional grants from Cordis J&J and Boston Scientific. Dittmar Böckler is a consultant for Medtronic, Endologix and W. L. Gore. Mark Eskandari is a consultant/course director for Endologix and W. L. Gore. Mila Ju is partially supported by National Institutes of Health Grant No. 5T32HL094293. Ashraf Mansour received funding from the National Institutes of Health and was a principal investigator for CREST, CHOICE, Capture-2 carotid stent trials or registries. Some of the patients included in the study were enrolled in one of those trials/registries. He was paid for follow-up on CREST, not for the other trials. Djordje Radak and Tanaskovic Slobodan are partly funded by the Serbian ministry of Science and Technological Development, Project No. 41002. Robert Rosenwasser has received grants from NIH and Cordis Corporation for CREST and SAPPHIRE trials. The other authors have no relevant disclosures or funding sources to report.

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