LAUSR

OBJECTIVE In-stent restenosis (ISR) hinders the long-term patency of carotid artery stenting (CAS), yet no optimal treatment has been established. This study was aimed to compare outcomes of re-do CAS (rCAS) and carotid endarterectomy (CEA) for ISR. METHODS A systematic search with the terms "in-stent restenosis", "carotid endarterectomy", and "carotid artery stenting" was conducted in the PubMed, Embase and Cochrane databases. Studies reporting perioperative stroke, death, and other important complications of rCAS or CEA for ISR after previous CAS with 4 or more patients were included. Pooled and sensitivity analysis were conducted to synthesize and compare estimates of outcomes. RESULTS A total of 11 articles with 1,057 patients receiving rCAS (n=894) or CEA (n=163) met the inclusion criteria. CEA group had significant higher proportion of symptomatic patients (rCAS vs. CEA: 30.4% vs. 42.1%, P<0.01). The duration from primary CAS to reintervention was relatively longer in CEA group (rCAS vs. CEA: median (range) 8.8 (3-26) vs. 19.9 (0-54) months). In the rCAS group, a higher proportion of patients had hypertension, hypercholesterolemia and coronary artery disease and received pre-reintervention antiplatelet therapy. Due to insufficient data or low incidence, the only complications feasible for further analysis were restenosis, myocardial infarction (MI), cranial nerve injury and neck hematoma. No significant differences were found in terms of primary endpoint of mortality/stroke event-free rate (rCAS vs. CEA: 99% vs. 98%, P>0.05) or other secondary endpoints (rCAS vs. CEA: event-free of restenosis, 100% vs. 100%; event-free of MI, 100% vs. 98%; event-free of cranial nerve injury, 100% vs. 98%; event-free of neck hematoma, 100% vs. 100%; all P>0.05). CONCLUSIONS Re-do carotid artery stenting is commonly used to treat patients with severe and/or symptomatic ISR after primary CAS. Although endovascular approach is a less invasive procedure, both rCAS and CEA can be performed safely with similar short- and mid-term outcomes of stroke, death, and surgery-related complications.