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Patterns Of In-Stent Restenosis After Carotid Artery Stenting: Implications For Long-Term Outcome

Brajesh K Lal¹, Elias A Kaperonis², Robert W Hobson, II¹, Salvador Cuadra¹, Indu Kapadia.^3
1UMDNJ-New Jersey Medical School, Newark, NJ; ²University Of Athens, Athens, Greece; ³Saint Michael's Medical Center, Newark, NJ.

OBJECTIVES: Factors predicting recurrence (in-stent restenosis, ISR) and future need for therapeutic re-intervention (target lesion revascularization, TLR) after carotid artery stenting (CAS) remain undetermined. We hypothesized that the patterns of restenotic lesions may provide prognostic information. In this study, we 1) developed a novel ultrasound (US) classification scheme for ISR based on lesion length and distribution, and 2) assessed factors that may predict the need for TLR.

METHODS: Patients were followed after CAS with B-mode US, and ISR lesions (≥50% stenosis) were classified into: type I (focal ≤10 mm end-stent lesions), II (focal ≤10 mm, intra-stent), III (diffuse >10 mm, intra-stent), IV (diffuse >10 mm proliferative, extending outside the stent), and V (total occlusion). The frequency of lesion types was assessed. Accuracy of the US classification was confirmed with angiography. Patient (age, gender, co-morbidities), lesion (severity, etiology, symptomatic status) and procedural features (type, number, length of stents), and the need for TLR, were recorded.

RESULTS: 80 ISR lesions developed after 235 CAS procedures. Their % distribution was 40, 26.3, 12.5, 20 and 1.3 (types I through V respectively). Accuracy of the US classification was confirmed by angiography (R2=0.79). 13 lesions were ≥80% diameter reducing, and underwent TLR. On univariate analysis, the need for TLR was highest in type IV lesions (0, 0, 20 and 56.3%; types I to IV respectively; p=0.001). A history of prior ISR (3.1, 0, 0 and 43.8%; types I to IV; p=0.001) and of diabetes (18.8, 28.6, 30 and 50%; types I to IV; p=0.02) occurred more frequently with type IV ISR lesions. On multivariate analysis of all patient, lesion and procedural characteristics, only the type of ISR (odds ratio, 9.5) and a history of diabetes (OR, 9.2) were independent predictors of TLR.

CONCLUSIONS: The proposed classification accurately grades the magnitude of intimal hyperplasia after CAS and provides important prognostic information. Diffuse proliferative (type IV) ISR lesions and diabetes are important determinants of long-term outcome after CAS. This classification will facilitate a standardized description of recurrence after CAS, and enable early identification of high-risk patients for additional monitoring, treatment and investigation.