The radiation-induced carotid stenosis: preoperative and late complications of surgical and endovascular treatment

AIM: Surgical treatment of radio--induced carotid stenosis (RICS) is challenging and burdened with high risk of complications. Carotid stenting (CAS) may be a valid alternative, but better approach is still not defined. Two approaches have been assessed in this an observational monocentric study, focusing on perioperative and follow--up complications. METHODS: From 2005 to 2013, data on patients treated for extracranial carotid stenosis with previous radiotherapy(RT) for head or neck tumor were prospectively collected according to the procedure performed (open repair [OR],endovascular stenting [CAS]). Patient demographics, clinical risk factors, organ of cancer origin, elapsed time from RT, duplex ultrasound(DUS) and clinical presentation of carotid stenosis were preoperatively gathered. Primary outcomes were technical success, 30--day mortality, transient ischemic attack(TIA)/stroke and myocardial infarction(MI). In OR group, laterocervical hematoma and cranial nerve injury were evaluated and, in CAS group, arterial access site complications were considered as well. Secondary outcomes were the mortality, TIA/stroke, restenosis and reintervention during follow--up. RESULTS: Fifteen RICS were treated in 12 patients (M/F=9/3;;median age:71years,range:51--80). OR was performed to treat 8 RICS in 5patients (M/F=3/2;;median age:65,range:50--76) and CAS to treat 7 RICS in 7 patients (M/F=6/1;;median age:75,range 59--80).In OR group, all patients were asymptomatic and all plaques were hypoechogenic at DUS with histological features of vulnerable plaque. Technical success was 100%. Thirty day mortality was 12.5% (1death for upper airways complication in patient with previous neck surgery). TIA/stroke and MI rate were 0% and cranial nerve injury 12.5%. In CAS group, carotid stenosis was symptomatic in 2(28.6%) cases, all plaques resulted hypoechogenic at DUS. Technical success was100%. Thirty--day mortality was0%. TIAoccurred in 4(57.1%) patients. No stroke, MI or access site hematoma occurred in this group. Mean follow--up was35.5 months±18.2.At12 and 36 month, freedom from any neurological event, from restenosis and from reintervention were all 100%. At1 and 3 years, survival was 91.7% and 81.5%, respectively. No patient died for carotid--related or cardiovascular causes. CONCLUSIONS: According with the plaque morphology and the high rate of cerebrovascular complications of CAS, OR should be suggested as the first choice for treatment of RICS in the majority of cases. In patients with previous neck surgery, assessment of airways is necessary before OR to avoid respiratory complications.