Neoatherosclerosis: A Distinctive Pathological Mechanism of Stent Failure.

With the development of drug-eluting stents, intimal re-endothelialisation is significantly inhibited by antiproliferative drugs, and stent restenosis transforms from smooth muscle cell proliferation to neoatherosclerosis (NA). As a result of the development of intravascular imaging technology, the incidence and characteristics of NA can be explored in vivo, with some progress made in illustrating the mechanisms of NA. Experimental studies have shed light on the molecular characteristics of NA. More critically, sufficient evidence proves NA as a significant cause of late stent failure. Treatments for NA are still being explored. In this review, we summarise the histopathological characteristics of different types of stent NA, explore the potential relationship of NA with native atherosclerosis and discuss the clinical significance of NA in late stent failure and the promising present and future prevention and treatment strategies.

Contrast-enhanced excimer laser stepwise approach during PCI for resistant coronary lesions.

BACKGROUND: The treatment of resistant coronary lesions (RCL) is a great challenge for interventional cardiologists. The excimer laser coronary atherectomy (ELCA) is a plaque modification tool based on a main mechanism of photomechanical effect leading to mechanical disruption of the plaque. Contrast dye injection during laser delivery has demonstrated to enhance its power. AIM: To evaluate the effectiveness and safety of the contrast-enhanced ELCA by a stepwise approach in the treatment of RCLs. METHODS: We retrospectively examined consecutive patients undergoing contrast-enhanced ELCA-assisted PCI between 2018 and 2021 at two Italian sites. RCLs were defined as novo or in-stent undilatable/uncrossable with conventional balloons (SC/NC balloon). The primary endpoint was ELCA technical success defined as the laser catheter crossing the entire length of the target lesion established by angiographic evidence of the catheter tip in the artery distal to the stenosis. RESULTS: We enrolled 114 patients who underwent contrast-enhanced ELCA-assisted PCI: 58% of the patients had acute coronary syndrome while the left anterior descending artery was the target vessel in 42.1% of cases. The target lesion was most commonly in-stent (56.2%). The 0.9 mm ELCA catheter tip was employed in 89.5% of cases. The most used frequency/fluency profile was 70/70 (39.5%). The use of contrast-enhanced ELCA was associated with high technical, procedural, and clinical success rates (97.4%, 93.7%, and 90.1%, respectively). CONCLUSIONS: The contrast-enhanced ELCA seems to be a safe and effective treatment option for the management of both de novo and in-stent-resistant coronary lesions.

Rivaroxaban and Aspirin in Drug-Coated Balloon Angioplasty for Femoropopliteal In-Stent Restenosis: a retrospective cohort study.

BACKGROUND: After drug-coated balloon (DCB) treatment of the femoropopliteal artery in-stent restenosis (ISR), a certain proportion of patients also experience target lesion restenosis. The purpose of this study was to explore the efficacy and safety of rivaroxaban combined with aspirin in the treatment of ISR after DCB intervention. METHODS: Patients who underwent DCB treatment for ISR after femoropopliteal artery intervention at our center from March 2017 to February 2022 were included consecutively. According to the drug treatment after DCB intervention of ISR, the patients were divided into rivaroxaban and aspirin group (RA Group) and dual antiplatelet therapy (DAPT) group. The outcomes of two groups during the 12-month follow-up after DCB intervention were compared. RESULTS: A total of 92 patients were included in final analysis, with 43 in RA group and 49 in DAPT group. During 12-month follow-up, a total of 15 cases of recurrent ISR were detected, and the recurrence rate of ISR and clinically driven TLR in the RA group were lower than those in the DAPT group (P<0.05). The vascular patency rate in the RA group was higher than that in the DAPT group at 6 and 12 months of follow-up (P<0.05). During the follow-up, there were no adverse events such as death, myocardial infarction, stroke, amputation, or major bleeding, and only a total of 5 cases of minor bleeding occurred. CONCLUSION: Compared with the standard DAPT regimen, rivaroxaban combined with aspirin can safely improve the follow-up outcome after DCB for femoropopliteal ISR.

Meta-Analysis Comparing Drug-Coated Balloon Versus Plain Old Balloon Angioplasty for In-stent Restenosis of Coronaries.

BACKGROUND: Despite the advent of newer stents, in-stent restenosis has been a persistent and formidable challenge. Trials have demonstrated the superiority of drug-coated balloons (DCB) over plain-old balloon angioplasty (POBA). A recent AGENT IDE trial highlighted the need for a more comprehensive understanding hence we conducted a meta-analysis aimed at elucidating their respective clinical outcomes. METHODS: A literature search was conducted by 2 investigators (SS and MH) using MEDLINE (EMBASE and PubMed) using a systematic search strategy by PRISMA till November 01, 2023. CRAN-R software was used for statistical analysis. The quality assessment was performed using the Cochrane Risk of Bias tool (Supplemental Table 5). RESULTS: We included 6 studies with a total of 1171 patients. Our analysis showed decreased odds of multiple outcomes with statistically significant results including TVR (OR 0.33, CI 0.19-0.57), TVF (OR 0.30, CI 0.09-0.99), TLR (OR 0.22, CI 0.10-0.46), restenosis (OR 0.1343, CI 0.06-0.27), and MACE (OR 0.2 CI 0.12-0.37). Although MI and all-cause mortality showed decreased odds with all-cause mortality at 0.8 (95% CI: 0.363-2.09), and MI at 0.6 (95% CI: 0.0349-1.07), the reductions did not reach statistical significance. CONCLUSION: Our analysis by scrutinizing six RCTs favored DCB over POBA. However, extensive research for deeper understanding cannot be overemphasized.

Comparative efficacy of drug-eluting balloon and drug-eluting stent for treatment of in-stent restenosis: a systematic review and meta-analysis.

OBJECTIVE: To compare the efficacy of drug-eluting stents and drug-eluting balloons in treating in-stent restenosis. METHODS: The systematic review was conducted from January to February 2022, and comprised literature search on PubMed, ProQuest, Cochrane Library and Google Scholar databases with relevant key words to locate randomised controlled trials and observational studies published between 2000 and 2022 that compared drugeluting balloons and drug-eluting stents in the treatment of in-stent restenosis. The outcomes were all-cause death, cardiovascular death, major adverse cardiovascular events, myocardial infarction, stent thrombosis, stroke and target vessel revascularisation. The pooled risk ratio for each outcome was analysed. Data was analysed using Review Manager 5.1. RESULTS: Of the 1,105 studies identified, 11(0.99%) were analysed in detail; 7(63.6%) randomised controlled trials and 4(36.4%) observational studies. There were 2,437 patients with in-stent restenosis. There was no significant difference between drug-eluting balloons and drugeluting stents with respect to all-cause death, cardiovascular death, stroke, stent thrombosis, myocardial infarction and major adverse cardiovascular events (p>0.05). Drug-eluting stents significantly caused more target vessel revascularisation compared to drugeluting balloons (p=0.004). CONCLUSIONS: Except for target vessel revascularisation, the drug-eluting balloons and drug-eluting stents had no difference in terms of clinical outcomes related to in-stent restenosis patients.

In silico model of stent performance in multi-layered artery using 2-way fluid-structure interaction: Influence of boundary conditions and vessel length.

BACKGROUND AND OBJECTIVE: Atherosclerotic lesions of coronary arteries (stenosis) are caused by the buildup of lipids and blood-borne substances within the artery wall. Their qualitative and rapid assessment is still a challenging task. The primary therapy for this pathology involves implanting coronary stents, which help to restore the blood flow in atherosclerosis-prone arteries. In-stent restenosis is a stenting-procedure complication detected in about 10-40% of patients. A numerical study using 2-way fluid-structure interaction (FSI) assesses the stenting procedure quality and can decrease the number of negative post-operative results. Nevertheless, boundary conditions (BCs) used in simulation play a crucial role in implementation of an adequate computational analysis. METHODS: Three CoCr stents designs were modelled with the suggested approach. A multi-layer structure describing the artery and plaque with anisotropic hyperelastic mechanical properties was adopted in this study. Two kinds of boundary conditions for a solid domain were examined - fixed support (FS) and remote displacement (RD) - to assess their impact on the hemodynamic parameters to predict restenosis. Additionally, the influence of artery elongation (short-artery model vs. long-artery model) on numerical results with the FS boundary condition was analyzed. RESULTS: The comparison of FS and RD boundary conditions demonstrated that the variation of hemodynamic parameters values did not exceed 2%. The analysis of short-artery and long-artery models revealed that the difference in hemodynamic parameters was less than 5.1%, and in most cases, it did not exceed 2.5%. The RD boundary conditions were found to reduce the computation time by up to 1.7-2.0 times compared to FS. Simple stent model was shown to be susceptible to restenosis development, with maximum WSS values equal to 183 Pa, compared to much lower values for other two stents. CONCLUSIONS: The study revealed that the stent design significantly affected the hemodynamic parameters as restenosis predictors. Moreover, the stress-strain state of the system artery-plaque-stent also depends on a proper choice of boundary conditions.

Usefulness of the Systemic Inflammation Response Index and the Systemic Immune Inflammation Index in Predicting Restenosis After Stent Implantation.

Purpose: The systemic inflammation response index (SIRI) and the systemic immune inflammation index (SII) are indicators that reflect the body's overall systemic inflammatory response. Inflammation plays an important role in the pathogenesis of in-stent restenosis (ISR). The aim of this study was to investigate the predictive value of preoperative SIRI and SII for the occurrence of ISR in patients undergoing coronary stent implantation. Materials and Methods: We retrospectively analyzed the clinical, hematological, and angiographic data of 387 patients who underwent coronary angiography for recurrent angina after coronary stent implantation at Qilu Hospital of Shandong University. Receiver operating characteristic curve (ROC) analysis was used to determine the optimal cutoff values for SIRI and SII to predict ISR. Based on the optimal cutoff values for SIRI and SII, patients were categorized into high-SIRI, low-SIRI, high-SII, and low-SII groups. Multivariate logistic regression models were constructed to assess the predictive value of SIRI and SII for ISR >50% and ISR >70%. Results: This study included a total of 387 patients who underwent coronary angiography and follow-up at Qilu Hospital of Shandong University. Patients in the high-SIRI group had a higher incidence of ISR than those in the low-SIRI group (ISR >50%: 44.8% vs 30.7%, p = 0.018; ISR >70%: 41.5% vs 4.5%, p < 0.001). In addition, ISR occurred more frequently in patients with a higher SII than in patients with a lower SII (ISR >50%: 52.6% vs 35.7%, p = 0.001; ISR >70%: 51.9% vs 23%, p < 0.001). In multivariate logistic regression analysis, SIRI and SII were found to be independent predictive factors for ISR, both as continuous and categorical variables. In the ROC analysis, the optimal cutoff value for SIRI was set at 0.54 (sensitivity: 84.5%, specificity: 27%), and the optimal cutoff value for SII was set at 545.29 (sensitivity: 44.1%, specificity: 71.7%). Conclusion: Elevated preoperative SIRI and SII values help predict ISR and may serve as a useful screening tool to perform interventional procedures based on the patient's risk of ISR after stent implantation.

Long-Term Outcomes Following Sirolimus-Coated Balloon or Drug-Eluting Stents for Treatment of In-Stent Restenosis.

BACKGROUND: Evidence suggests that drug-coated balloons may benefit in-stent restenosis (ISR) treatment. However, the efficacy of new-generation sirolimus-coated balloon (SCB) compared with the latest generation drug-eluting stents (DESs) has not been studied in this setting. METHODS: All patients in the EASTBORNE (The All-Comers Sirolimus-Coated Balloon European Registry) and DEB-DRAGON (DEB vs Thin-DES in DES-ISR: Long Term Outcomes) registries undergoing percutaneous coronary intervention for DES-ISR were included in the study. The primary study end point was target lesion revascularization at 24 months. Secondary end points were major adverse cardiovascular events, all-cause death, myocardial infarction, and target vessel revascularization at 24 months. Our goal was to evaluate the efficacy and safety of SCB versus thin-struts DES in ISR at long-term follow-up. RESULTS: A total of 1545 patients with 1679 ISR lesions were included in the pooled analysis, of whom 621 (40.2%) patients with 621 lesions were treated with thin-strut DES and 924 (59.8%) patients with 1045 lesions were treated with SCB. The unmatched cohort showed no differences in the incidence of target lesion revascularization (10.8% versus 11.8%; P=0.568); however, there was a trend toward lower rates of myocardial infarction (7.4% versus 5.0%; P=0.062) and major adverse cardiovascular events (20.8% versus 17.1%; P=0.072) in the SCB group. After propensity score matching (n=335 patients per group), there were no significant differences in the rates of target lesion revascularization (11.6% versus 11.8%; P=0.329), target vessel revascularization (14.0% versus 13.1%; P=0.822), myocardial infarction (7.2% versus 4.5%; P=0.186), all-cause death (5.7% versus 4.2%; P=0.476), and major adverse cardiovascular event (21.5% versus 17.6%; P=0.242) between DES and SCB treatment. CONCLUSIONS: In patients with ISR, angioplasty with SCB compared with thin-struts DES is associated with comparable rates of target lesion revascularization, target vessel revascularization, myocardial infarction, all-cause death, and major adverse cardiovascular events at 2 years.

Subclavian-Carotid Bypass as a Solution to Recurrent Carotid Artery Stenosis Post Endarterectomy and Transfemoral Stenting.

We present the case of an 80-year-old man who underwent a subclavian-to-distal internal carotid artery bypass with a reversed saphenous vein due to symptomatic in-stent restenosis, following a carotid endarterectomy 20 years ago and carotid artery stenting 10 years ago. The patient presented with right-sided hemiparesis and dysarthria. Imaging suggested in-stent restenosis of the internal carotid artery stent. He was also found to have stenosis of the common carotid artery origin stent. An initial transfemoral attempt by interventional radiology was unsuccessful. Due to the stenosed common carotid artery origin stent, a common carotid-to-internal carotid artery bypass was not feasible. Therefore, a subclavian-distal carotid artery bypass with a reversed saphenous vein was performed. He did well in the postoperative period and has been seen in the clinic since. Surveillance ultrasound demonstrated a patent graft with non-stenotic proximal and distal anastomoses. We include an in-depth review of the management of recurrent carotid artery stenosis as well.

A risk score for predicting in-stent restenosis in patients with premature acute myocardial infarction undergoing percutaneous coronary intervention with drug-eluting stent.

Background: This study aimed at developing and validating a risk score to predict in-stent restenosis (ISR) in patients with premature acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES). Methods: This was a two-center retrospective study. A total of 2185 patients firstly diagnosed with premature AMI (age ≥18 years and <55 years in men, <65 years in women) from Xinjiang cohort were retrospectively analyzed. After filtering by exclusion criteria, patients were randomly divided into training cohort (n = 434) and internal validation cohort (n = 186) at a 7:3 ratio. Several candidate variables associated with ISR in the training cohort were assessed by the least absolute shrinkage and selection operator and logistic regression analysis. The ISR risk nomogram score based on the superior predictors was finally developed, and then validated in the internal validation cohort and in an independent Chengdu external validation cohort (n = 192). The higher total nomogram score, the greater the ISR risk. Results: The eight variables in the final risk nomogram score, cardiovascular-kidney-metabolic (CKM) score included age, diabetes mellitus (DM), body mass index (BMI), systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDLC), estimated glomerular filtration rate (eGFR), stent in left anterior descending coronary artery, minimum stent diameter <3 mm. The areas under the curve (AUC) and C-statistics [training cohort: 0.834 (95%CI: 0.787 to 0.882); internal validation cohort: 0.852 (95%CI: 0.784 to 0.921); Chengdu external validation cohort: 0.787 (95%CI: 0.692 to 0.882), respectively)] demonstrated the good discrimination of the CKM score. The Hosmer-Lemeshow test (χ2 = 7.86, P = 0.448; χ2 = 5.17, P = 0.740; χ2 = 6.35, P = 0.608, respectively) and the calibration curve confirmed the good calibration of the CKM score. Decision curve analysis (DCA) testified the clinical net benefit of the CKM score in the training and validation cohort. Conclusion: This study provided a well-developed and validated risk nomogram score, the CKM score to predict ISR in patients with premature AMI undergoing PCI with DES. Given that these variables are readily available and practical, the CKM score should be widely adopted for individualized assessment and management of premature AMI.

Elucidating the Relationship between Neutrophil-Lymphocyte Ratio and Plaque Composition in Patients with Drug-Eluting Stent Restenosis by Virtual Histology-Intravascular Ultrasound.

(1) Background: In-stent Restenosis (ISR) is a major factor influencing the prognosis and revascularization of target lesions. The plaque composition is unclear; therefore, it is critical to investigate ISR composition to identify clinical intervention markers. (2) Methods: This study was conducted on 36 patients with drug-eluting stent restenosis. The patients were classified into a Low Neutrophil-Lymphocyte Ratio (L-NLR) and High Neutrophil-Lymphocyte Ratio (H-NLR) according to the median NLR level of 36 patients. Discrepancies in the current information such as baseline data, biochemical examination, cardiac ultrasound data, etc., were examined to identify the underlying risk factors, and a multifactorial linear regression analysis of plaque properties was conducted. (3) Results: NLR = 2.64 was utilized to classify 18 patients into the L-NLR group and 18 patients into the H-NLR group. There were statistically significant differences in age, a pre-percutaneous coronary intervention (PCI) SYNTAX II score, a C-reactive protein (CRP), interleukin (IL)-6, plaque loading, a fibro-lipid tissue area, calcified nubs, and virtual histology-thin fibrous cap atherosclerotic (VH-TCFA). The significant impacts of variations in age, neutrophil-lymphocyte ratio (NLR) levels, and IL-6 levels on the plaque stress and percentage of the fibro-lipid tissue in virtual histology-intravascular ultrasound (VH-IVUS) were identified through multifactorial linear regression. (4) Conclusions: The high NLR group demonstrated increased myocardial injury severity, consistent with higher SYNTAX II scores, a higher plaque burden, and higher proportions of vulnerable components. NLR proved to be a risk factor for both the plaque load and the proportion of the fibro-lipid tissue in ISR.

In-stent restenosis caused by a reprotruding calcified nodule and stent fracture in the hinged coronary artery.

Calcified nodules (CNs) cause in-stent restenosis (ISR) frequently. Although reprotrusion of CNs through stent struts is one of the mechanisms of ISR, the process of this phenomenon has not been understood. Furthermore, little is known about stent fracture (SF) occurring at the site of CNs. We are presenting a case of an 82-year-old male who developed early ISR due to the combination of an in-stent CN and SF in the hinged right coronary artery. The process of progression of the in-stent CN was recorded sequentially with angiography and intravascular ultrasound (IVUS). IVUS from the fulcrum of hinge motion revealed the repetitive protruding movement of the CN into the stent lumen.

Comparison of Drug-Coated Balloons With Drug-Eluting Stents in Patients With In-Stent Restenosis: A Systematic Review and Meta-Analysis.

In-stent restenosis (ISR) is the gradual narrowing of the stented coronary segment, presenting as angina or leading to an acute myocardial infarction. Although its incidence has decreased with the use of newer drug-eluting stents (DES), it still carries significant mortality and morbidity risks. We compared the 2 most common interventions for managing DES-related ISR: drug-coated balloons (DCBs) and DES. Electronic databases were searched to identify all randomized controlled trials comparing DCB with DES in patients with DES-ISR. The Mantel-Haenszel method with a random-effects model was used to calculate pooled risk ratios. Five trials comprising 1,100 patients (577 in DCB and 523 in DES group) were included in the final study. The mean follow-up was 42 months. DCB was found to have a higher risk for target lesion revascularization (risk ratio 1.41, p = 0.02) compared with DES. No difference was observed in all-cause mortality, target vessel revascularization, myocardial infarction, or stroke between the 2 intervention arms. In conclusion, management of DES-ISR with DCB has a higher risk of target lesion revascularization compared with re-stenting with DES. The 2 therapeutic interventions are comparable in terms of efficacy and safety profile.

Cucurbitacins mitigate vascular neointimal hyperplasia by suppressing cyclin A2 expression and inhibiting VSMC proliferation.

BACKGROUND: Restenosis frequently occurs after percutaneous angioplasty in patients with vascular occlusion and seriously threatens their health. Substantial evidence has revealed that preventing vascular smooth muscle cell proliferation using a drug-eluting stent is an effective approach to improve restenosis. Cucurbitacins have been demonstrated to exert an anti-proliferation effect in various tumors and a hypotensive effect. This study aims to investigate the role of cucurbitacins extracted from Cucumis melo L. (CuECs) and cucurbitacin B (CuB) on restenosis. METHODS: C57BL/6 mice were subjected to left carotid artery ligation and subcutaneously injected with CuECs or CuB for 4 weeks. Hematoxylin-Eosin, immunofluorescence and immunohistochemistry staining were used to evaluate the effect of CuECs and CuB on neointimal hyperplasia. Western blot, real-time PCR, flow cytometry analysis, EdU staining and cellular immunofluorescence assay were employed to measure the effects of CuECs and CuB on cell proliferation and the cell cycle in vitro. The potential interactions of CuECs with cyclin A2 were performed by molecular docking. RESULTS: The results demonstrated that both CuECs and CuB exhibited significant inhibitory effects on neointimal hyperplasia and proliferation of vascular smooth muscle cells. Furthermore, CuECs and CuB mediated cell cycle arrest at the S phase. Autodocking analysis demonstrated that CuB, CuD, CuE and CuI had high binding energy for cyclin A2. Our study also showed that CuECs and CuB dramatically inhibited FBS-induced cyclin A2 expression. Moreover, the expression of cyclin A2 in CuEC- and CuB-treated neointima was downregulated. CONCLUSIONS: CuECs, especially CuB, exert an anti-proliferation effect in VSMCs and may be potential drugs to prevent restenosis.

Machine Learning-Based Prediction of In-Stent Restenosis Risk Using Systemic Inflammation Aggregation Index Following Coronary Stent Placement.

Introduction: Coronary artery disease (CAD) remains a significant global health challenge, with percutaneous coronary intervention (PCI) being a primary revascularization method. In-stent restenosis (ISR) post-PCI, although reduced, continues to impact patient outcomes. Inflammation and platelet activation play key roles in ISR development, emphasizing the need for accurate risk assessment tools. The systemic inflammation aggregation index (AISI) has shown promise in predicting adverse outcomes in various conditions but has not been studied in relation to ISR. Methods: A retrospective observational study included 1712 patients post-drug-eluting stent (DES) implantation. Data collected encompassed demographics, medical history, medication use, laboratory parameters, and angiographic details. AISI, calculated from specific blood cell counts, was evaluated alongside other variables using machine learning models, including random forest, Xgboost, elastic networks, logistic regression, and multilayer perceptron. The optimal model was selected based on performance metrics and further interpreted using variable importance analysis and the SHAP method. Results: Our study revealed that ISR occurred in 25.8% of patients, with a range of demographic and clinical factors influencing the risk of its development. The random forest model emerged as the most adept in predicting ISR, and AISI featured prominently among the top variables affecting ISR prediction. Notably, higher AISI values were positively correlated with an elevated probability of ISR occurrence. Comparative evaluation and visual analysis of model performance, the random forest model demonstrates high reliability in predicting ISR, with specific metrics including an AUC of 0.9569, accuracy of 0.911, sensitivity of 0.855, PPV of 0.81, and NPV of 0.948. Conclusion: AISI demonstrated itself as a significant independent risk factor for ISR following DES implantation, with an escalation in AISI levels indicating a heightened risk of ISR occurrence.

Comparative Analysis of Balloon Angioplasty Alone versus Carotid Artery Stenting for Severe Extracranial Carotid Artery Stenosis: A Four-Year Retrospective Study.

BACKGROUND: This retrospective study aimed to compare the efficacy of balloon angioplasty alone (BAA) with carotid artery stenting (CAS) for severe extracranial carotid artery stenosis (ECAS). The primary outcomes assessed were restenosis requiring retreatment and symptomatic stroke occurrence within a four-year follow-up period. METHODS: A total of 77 patients with 89 carotid artery stenoses undergoing endovascular carotid revascularization (ECR) between January 2015 and December 2019 were included. Neuroradiological evaluations, including computed tomography angiography (CTA) or magnetic resonance angiography (MRA), were performed at defined intervals. Statistical analyses were conducted to compare patient characteristics, angiographic outcomes, and clinical outcomes between the BAA and CAS groups. RESULTS: The study demonstrated successful outcomes in both groups with low adverse event rates. The overall restenosis rate was 40.2%, but severe restenosis requiring retreatment occurred in only 10 cases (7 in BAA, 3 in CAS). No significant difference was found in retreatment rates between the two groups (p=0.53). Stroke occurrence within the four-year follow-up period was observed in three patients, with no statistically significant difference between BAA and CAS groups CONCLUSIONS: This study provides valuable insights into the comparative effectiveness of BAA and CAS for severe ECAS. Despite slightly shorter intervals to restenosis in the BAA group, there was no significant difference in retreatment or stroke occurrence rates between the two procedures. BAA offers advantages in terms of retreatment options.