Recurrent carotid stenosis after conventional carotid endarterectomy: location of the lesions

Aim. The aim of this study was to investigate the most frequent sites of involvement in cases of recurrent carotid stenosis (RCS) following carotid endarterectomy (CEA), in an attempt to clarify the pathogenic mechanisms underlying their development. Methods. The authors retrospectively analyzed a series of 1 449 patients subjected to conventional CEAs over a 13-year period and identified all cases of RCS >= 70% detected during follow-up. Lesions were classified according to their locations within 5 zones of the carotid bifurcation, from the common carotid artery (CCA, zone 1) to the internal carotid artery (ICA, zone 5). Results. The mean follow-up was 67 months. RCS was documented in 91 (5.8%) of the 1 576 carotids operated on. The mean time of recurrence was 6.3 months. Compared with the total series, the RCS subgroup presented a 2-fold increase in the percentage of women (male:female ratio 3.2 vs 1.6, P=0.04) and a similar to 3-fold increase in the prevalence of hypercholesterolemia (41.8% vs 15.8%, P<0.0001). Primary arterial closure and patch angioplasty were associated with similar RCS rates (5.7% vs 6.1%). Well over half the RCS lesions were in the ICA (zone 4 [30.1%] or 5 [39.8%]), and these locations were significantly more frequent than zones 1 (3.6%), 2 (4.8%), and 3 (21.7%) (P=0.002) regardless whether the arteriotomy was closed with direct suturing or patch angioplasty. Conclusion. The ICA was the most susceptible to RCS regardless of the type of closure used. The authors discuss possible pathogenic mechanisms underlying RCS that could explain the preferential location of these lesions in the ICA.