1. Patch, Bypass or Stent for Restenosis following Carotid Endarterectomy Th. Hölzenbein 1, M. Aspalter 1, K. Linni 1, N. Mader 1, W. Hitzl 2, A. Ugurluoglu 1 1 Department for Vascular and Endovascular Surgery, 2 Research Office PMU Salzburg Paracelsus Medical University Salzburg, Austria

2. Background Recurrent Stenosis after Endarterectomy  Incidence 6,3%, 24 mos after surgery 1 1. year: 10%; 2. year: 3%; 3. u. 4. year: 2%; later: 1% 2  Indication for Intervention 3,4 - symptomatic stenosis - high grade asymptomatic stenosis (>80%)  Evidence / Management Guidelines 1 Lal BK et al. Lancet neurology 2012;11(9):755-63 2 Frericks H et al. Stroke 1998;29(1):244-50 3 Bekelis K et al. Br J Surg 2013;100(4):440–7 4 Johnson CA et al. Am J Surg 1999;177(5):433-6 Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

3. Purpose Study Goal Redo-Carotid-Intervention  Which intervention for witch lesion?  When to interveen for asymtomatic disease Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

4. Methods Observational period: 02/1997-03/2013  Retrospective Analysis of Consecutive Patients of the Department of Vascular and Endovascular Surgery  Inclusion criteria ALL patients who were treated for recurrent carotid stenosis  Indication for surgery Symptomatic recurrent stenosis ≥ 80% asymptomatic recurrent stenosis Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

5. Universitätsklinik für Vaskuläre und Endovaskuläre Chirurgie Salzburg | Dreiländertagung, Linz | M. Aspalter

6. rCEA (%), n=33CAB (%), n=32CAS (%), n=28p male24 (73)21 (66)14 (50)n.s. Age (median)71,970,870,6n.s. Left12 (36)16 (50)11 (39)n.s. BMI24,424,626,00,01 Risik factors Smoking12 (36)13 (41)3 (11)0,03 Hypertension28 (85)24 (75)24 (86)n.s. Hyperlipidemia21 (64)25 (78)23 (82)n.s. Diabetes7 (21)8 (25)10 (36)n.s. CAD21 (64)15 (47)15 (54)n.s. pAOD29 (61)13 (41)14 (50)n.s. Patients Demographic Data 93 Procedures in 89 Patients Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

7. Results Interval for redo surgery p = 0,04 p = n.s. p < 0,001 69% 46% 25% 21% 18% 6%7% Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

8. Results Preoperative symptoms / Degree of stenosis ipsilateral p = 0,02 p = n.s. Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

9. p = n.s. Results Degree of stenosis contralateral p = 0,04 p = 0,01 p = n.s. Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

10. Results: Open Surgery rCEA  28 (85%) vein patch; VSM n=25, VSP n=3  5 (15%) Dacron® patch  Procedural time: 138 min (median) CAB  30 (94%) vein  1 (3%) Dacron  1 (3%) ePTFE  Procedural time: 117 min (median) Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

11. Result: Endovascular Surgery CAS  13 (46%) Nitinol-Stent  10 (36%) Wallstent®  5 (18%) procdeure abandoned  3 Lesion not acessible  2 Neurologic symptoms during access  3 vein patch  1 Dacron patch  1 Bypass Technical success: 82% Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

12. rCEA (%), n=33CAB (%), n=32CAS (%), n=28p Hoarsenes8 (24)11 (34)00,004 Cranial nerve lesions 8 (24)12 (38)00,002 Intra-OP TIA / Insult 1 (3) / 1 (3). 3 (9) / 2 (6). 3 (11) / 2 (7). n.s. Myocardial infarct000- Bleeding3 (9)4 (13)0n.s. Insult + death2 (6)5 (16)6 (21)n.s. Results Early Complications Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

13. Results Reintervention – free - survival Time (years) Reintervention –free –Survival (cumulative) Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

14. Result Reintervention – free - survival Zeit (Jahre) Reinterventions-freies-Überleben (kumulativ)  CAS: significant more Reinterventions (25% at 4 years p=0.014) Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

15. Results Survival Time (years) Surrvival (cumulative) Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein

16. Conclusion  Infrequent clinical problem (relevance?)  Indication for redo intervention is currently under debate  Similar outcome of all 3 groups  Significant more reinterventions after CAS  In open surgery: bypass is not superior to patch in long term observation  Drawbacks: retrospective study, non randomized, small sample, single center  Difficult to obtain guidelines Department for Vascular and Endovascular Surgery Salzburg | T.Hölzenbein