Original Article
Periprocedural Cilostazol Treatment and Restenosis after Carotid Artery Stenting: The Retrospective Study of In-Stent Restenosis after Carotid Artery Stenting (ReSISteR-CAS)

https://doi.org/10.1016/j.jstrokecerebrovasdis.2010.06.007Get rights and content

Restenosis after carotid artery stenting (CAS) is a critical issue. Cilostazol can reduce restenosis after interventions in coronary or femoropopliteal arteries. We investigated whether periprocedural cilostazol treatment was related to the incidence of in-stent restenosis (ISR) or target vessel revascularization (TVR) after CAS. The study group comprised 553 of 580 patients who underwent CAS between April 2003 and August 2006 and were followed for 30 months after the procedure. ISR was defined as stenosis of at least 50% detected on angiography or ultrasonography. TVR was defined as revascularization of the treated carotid artery. During CAS, 207 patients (37.4%) were treated with cilostazol. Over 30 months, ISR occurred in 23 patients (4.2%), TVR occurred in 16 patients (2.9%), and either ISR or TVR occurred in 25 patients (4.5%). The incidence of ISR or TVR was significantly lower in the cilostazol-treated group than in the untreated group (1.4% vs 6.4%; log-rank P = .006). In a multivariate analysis, cilostazol treatment (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.08-0.95; P = .041) and stent diameter (HR, 0.73/1-mm increase; 95% CI, 0.54-0.99; P = .044) were independent factors for the occurrence of ISR or TVR. The incidence of a composite of events, including thromboembolism, hemorrhage, death, and TVR, tended to be lower in the cilostazol-treated group than in the untreated group (15.0% vs 19.9%; log-rank P = .17). Periprocedural cilostazol treatment was associated with lower rates of ISR and retreatment after CAS. A prospective randomized controlled trial is needed to clarify the effect of cilostazol on ISR after CAS.

Section snippets

Materials and Methods

The Retrospective Study of In-Stent-Restenosis after Carotid Artery Stenting (ReSISteR-CAS) study group comprised 11 Japanese stroke centers. In this study, consecutive patients who underwent CAS for atherosclerotic severe carotid stenosis in these 11 centers between April 2003 (when cilostazol was approved for ischemic stroke in Japan) and August 2006 were registered. The study included patients who could be observed over 30 months after CAS and underwent digital subtraction angiography (DSA),

Results

Of the 580 patients enrolled, 553 were analyzed. Of these, 207 patients (37.4%) were treated periprocedurally with cilostazol. The cilostazol dosage was 100 mg/day in 23 patients (11.1%), 150 mg/day in 3 patients (1.4%), and 200 mg/day in 181 patients (87.4%). Antiplatelet drugs other than cilostazol included aspirin (81–200 mg/day) in 485 patients (87.7%), ticlopidine (100–300 mg/day) in 322 patients (58.2%), and others (including clopidogrel) in 30 patients (5.4%).

Table 1 summarizes patient

Discussion

In this study, the composite incidence of ISR or TVR after CAS was lower in the treated group compared with the untreated group. In addition, cilostazol use and stent diameter were independently associated with the development of ISR after adjustment for other putative factors.

ISR within 30 months after CAS occurred in 4.2% of patients, and TVR was performed in 2.9%. Groschel et al8 reviewed reports on ISR after CAS between 1990 and 2004 and found an incidence of ≥50% postprocedural ISR of

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