Recurrent carotid stenosis. Results and complications of 57 operations

Among 1992 patients undergoing carotid endarterectomy from January 1972 through December 1984, 57 operations were performed in 51 patients for recurrent carotid stenosis. Thirty-four of these cases had undergone initial surgery at this institution while 23 had endarterectomy elsewhere. Fifty-two of the 57 operations were for symptomatic disease while five were for evidence of a progressing lesion. All operative procedures were monitored with intracerebral blood flow measurements and continuous electroencephalograms. Twenty-three patients required intraoperative shunting. There were no complications related to shunt usage or to the period of temporary occlusion in patients who did not require shunting. Recurrent stenosis was related to intimal hyperplasia in 14 cases, recurrent atherosclerosis with interluminal thrombi or degenerated plaque in 27, unexplained soft thrombus in eight, proximal scarring in six, and to aneurysms in two. Intimal hyperplasia was the most common cause for restenosis within 2 years from the date of surgery and developed earlier in patients with a primary closure than in patients closed with a patch graft. The operative complication rate was 10.5% or 4 times the risk of surgery for primary atherosclerosis at this institution. Complications were attributed primarily to intraoperative and postoperative thromboembolic events related to apparent increased thrombogenicity of these vessels. The highest complication rate occurred in the group of patients undergoing surgery for thrombotic material in the internal carotid artery, either primary or with underlying atherosclerosis. There were no neurological complications in the group with myointimal hyperplasia. The authors' experience suggests that on-lay patch grafting without endarterectomy should be used in patients with myointimal hyperplasia. Patients with complicated recurrent atherosclerosis can be treated with endarterectomy and patch grafting, but interposition vein grafts should be considered in cases in which the vessels are extensively damaged by the recurrent plaque or with an unexplained thrombus at the site of previous endarterectomy.