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• W2016911638 abstract "I read with great interest the Article by Brajesh K Lal and colleagues,1Lal BK Beach KW Roubin GS et al.for the CREST InvestigatorsRestenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial.Lancet Neurol. 2012; 11: 755-763Summary Full Text Full Text PDF PubMed Scopus (287) Google Scholar which focused on the results of a secondary analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). More than 2000 patients who underwent carotid endarterectomy or stenting were followed up for 2 years, 120 of whom had carotid restenosis or occlusion. The investigators reported that female sex, diabetes, and dyslipidaemia were independent predictors for restenosis or occlusion in both treatment groups and that smoking was a predictor in surgical patients only. Restenosis and occlusion occurred mainly in the first year of follow up. For this reason, analysis of the type of patients who had early restenosis according to clinical and procedural variables would be interesting. Additionally, a secondary analysis in the subgroup of patients with previous stroke or transient ishaemic attack using the lag time between cerebrovascular event and carotid treatment as a predictive variable for restenosis might also be useful. An important aspect of the subanalysis by Lal and colleagues was to show the clinical importance of the recurrence of carotid stenosis, with the finding that patients with carotid restenosis within 2 years had a higher risk of ipsilateral stroke than did those without restenosis. Therefore, we can infer that the middle-term and long-term clinical outlook of patients undergoing carotid endarterectomy or carotid artery stenting depends on the patency of the carotid artery after intervention. Mechanisms for the development of carotid restenosis are still being defined. However, two main processes appear to be fundamental: the neointimal hyperplasia that seems to occur in the first phase after a procedure, which has been mainly related to the vascular injury (surgical or endovascular)2Simon DI Inflammation and vascular injury: basic discovery to drug development.Circ J. 2012; 76: 1811-1818Crossref PubMed Scopus (70) Google Scholar and the atherosclerotic process that supports restenosis later. Factors associated with carotid restenosis include surgical defects in arterial wall closure or imperfect positioning of the carotid stent in the vessel. By contrast, atherosclerosis is often considered to be a dynamic process in which inflammatory and thrombotic mechanisms are involved. Two aspects of carotid restenosis management should be emphasised, as expressed in this secondary analysis of CREST: whether and how carotid restenosis should be treated, and whether preventive therapy could reduce the risk of restenosis. Although there is a general consensus about the need for intervention for carotid restenosis, the safest and most effective type of procedure is still debated.3Lal BK Recurrent carotid stenosis after CEA and CAS: diagnosis and management.Semin Vasc Surg. 2007; 20: 259-266Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar In the case of restenosis after carotid endarterectomy, some studies have provided evidence for the utility of carotid artery stenting, although whether management of restenosis after stenting should be with carotid endarterectomy or stenting is unclear. With respect to preventive therapy, much interest has been focused on the use of statins to reduce the risk of carotid restenosis4Perler BA The effect of statin medications on perioperative and long-term outcomes following carotid endartrectomy or stenting.Semin Vasc Surg. 2007; 20: 252-258Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar because of the pleiotropic actions of statins. Further analyses are needed to better define the type and dose of statins for the prevention of restenosis, especially because of the predictive role of dyslipidaemia in the secondary analysis of CREST. I declare that I have no conflicts of interest. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trialRestenosis and occlusion were infrequent and rates were similar up to 2 years after carotid endarterectomy and carotid artery stenting. Subsets of patients could benefit from early and frequent monitoring after revascularisation. Full-Text PDF Open AccessRestenosis after carotid endarterectomy and stenting – Authors' replyWe thank Simone Vidale for the interesting and important questions raised in her letter. As stated in our results section,1 our analysis did not show a difference in restenosis rates between procedures at either 2 year or 4 year follow-up. As such, we were unable to identify a treatment interaction with early or late restenosis. We agree that time from onset of symptoms to revascularisation versus restenosis rate could be a possible analysis, but we are unaware of any information to suggest that time would affect the restenosis rate. Full-Text PDF" @default.
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• W2016911638 title "Restenosis after carotid endarterectomy and stenting" @default.
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• W2016911638 doi "https://doi.org/10.1016/s1474-4422(12)70261-2" @default.
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