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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Mechanisms and Predictors of Carotid Artery Stent Restenosis

A Serial Intravascular Ultrasound Study

David J. Clark, MD^_*,, Sara Lessio, MD^_*,1, Margaret O’Donoghue, MD^_*, Con Tsalamandris, MD, Robert Schainfeld, DO^_* and Kenneth Rosenfield, MD, FACC^_*,_*

^_* Division of Cardiovascular Medicine and Research, St. Elizabeth’s Medical Center of Boston, Boston, Massachusetts
Departments of Cardiology and Medicine, Austin Hospital, Melbourne, Australia.

Manuscript received October 19, 2005; revised manuscript received January 2, 2006, accepted January 16, 2006.

^_* Reprint requests and correspondence: Dr. Kenneth Rosenfield, Cardiology Division, Massachusetts General Hospital, 55 Fruit Street, Gray/Bigelow 800, Mailstop 843, Boston, Massachusetts 02114. (Email: krosenfield{at}fastmail.us).

OBJECTIVES: The aim of this study was to determine the mechanisms and predictors of carotid artery restenosis after carotid artery stenting (CAS) using serial intravascular ultrasound (IVUS) imaging.

BACKGROUND: Carotid artery stenting is increasingly used to treat high-grade obstructive carotid disease, but our knowledge of carotid in-stent restenosis and remodeling remains limited.

METHODS: Post-procedural and 6-month (median 6 months) follow-up quantitative carotid angiography and IVUS were performed after self-expanding stent deployment in 50 internal carotid arteries (ICA). The IVUS measurements at multiple designated sites included minimal luminal diameter, lumen area, stent area (SA), and neointimal hyperplasia area (NIH).

RESULTS: Late stent enlargement at follow-up was found at all segments, and the percentage increase was greatest at the ICA lesion site (mean ± SD, 48.9 ± 35.3%). The NIH, expressed as a percentage of SA, was seen within all segments of the stent and was greatest at the ICA lesion site (37.3 ± 23.3%). There was a strong positive correlation between the amount of NIH and late stent enlargement (r = 0.64; p < 0.001). Immediate post-procedural minimum ICA SA (r = –0.37; p < 0.01) and stent expansion (r = –0.44; p = 0.001) correlated negatively with the percentage restenotic area at follow-up.

CONCLUSIONS: Although self-expanding carotid stents generate considerable neointimal hyperplasia, the process is balanced by marked late stent enlargement. Small stent dimensions immediately post-procedure were associated with a higher risk of restenosis.

Abbreviations and Acronyms   CAS = carotid artery stenting   CCA = common carotid artery   CEA = carotid endarterectomy   EEM = external elastic membrane   ICA = internal carotid artery   IVUS = intravascular ultrasound   LA = luminal area   MLD = minimal luminal diameter   NIH = neointimal hyperplasia area   QCA = quantitative carotid angiography   SA = stent area

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