In-Stent Stenosis Following Covered Stent-Graft Placement

Abstract

Internal carotid artery (ICA) covered stent-grafts are increasingly utilized for the endovascular management of traumatic carotid pseudoaneurysms 1 " 9 , carotid-cavernous fistulas 1012 , large petrous/cavernous carotid aneurysms 12 and carotid blow-out syndrome 7 . Early covered stent grafts were selffabricated using polytetrafluoroethylene or autologous vein mounted onto bare metal stents. Pre-mounted balloon expandable or self-expanding stent-grafts are now commercially available. Covered stents provide an alternate treatment option for high surgical risk or inaccessible lesions or when observation and anticoagulation are less than desirable. Potential advantages of covered stent grafts include minimal invasiveness, shorter hospital stays, lower cost and less post-procedural pain. Caution in the application of this relatively new technology and careful follow-up are required, however, as is illustrated by two patients with internal carotid artery stenosis following covered stent-graft placement. Case IA 24-year-old previously healthy right-handed woman was the belted driver in a vehicle roll-over. She sustained multiple injuries including fractures of the odontoid process of C2 and the left transverse process of C7. A computed tomogram (CT) head performed at the time of admission was unremarkable. The patient was sedated, intubated and treated with hypothermia according to the institutional protocol. As the sedation dissipated 24-hours later, the patient was found to be aphasic with mild right-sided face and arm weakness. A repeat CT head demonstrated a subacute left fronto-temporal infarct and CT angiography revealed left internal carotid artery (ICA) occlusion, presumed to be secondary to arterial dissection. Antiplatelet therapy was initiated at this time.The patient made a good functional recovery with significant improvement in speech and complete recovery of motor function. A one-month follow-up CT angiogram demonstrated recanalization of the left ICA but development of a pseudoaneurysm at the level of the first cervical vertebrae. Serial noninvasive angiography over three months demonstrated progressive enlargement of the pseudoaneurysm and consequently the patient was referred for endovascular management to prevent its continued expansion and decrease the future risk of a recurrent ischemic event.Given the angio-architecture of the pseudoaneurysm, covered stent graft placement or vessel occlusion were considered as the safest and effective treatment options. An approach preserving

Endovascular implantation of covered stents in the extracranial carotid and vertebral arteries: Case series and review of the literature

“…In-stent stenosis due to intimal hyperplasia was described in an additional three cases of traumatic ICA pseudoaneurysms,[347379] as also one case of a VA pseudoaneurysm with multiple AVFs. [92] McNeil et al .,[73] and Flood et al .,[34] each reported 50% ICA in-stent stenosis following placement of a Wallgraft and Jostent at 10 months and one year, respectively.…”

“…[92] McNeil et al .,[73] and Flood et al .,[34] each reported 50% ICA in-stent stenosis following placement of a Wallgraft and Jostent at 10 months and one year, respectively. Parodi et al .,[79] reported 90% ICA in-stent stenosis following placement of a vein-covered Palmaz stent, which progressed to complete occlusion 39 months after initial covered stent placement.…”

“…These publications are summarized in Table 1. [12457811131516192527–3234353738414245495152545759–63656668–7375–77798082–858789–9294–98100101103104106109112–114]…”

Commentary: New Generation of Covered Stents for the Treatment of Intracranial Aneurysms

“…Significant instent stenosis and delayed vessel occlusion have been reported as a complication after the use of covered stents in the cerebral circulation. 6 Double antiplatelet agents are generally used for 6 months or longer but may be associated with a small increased risk of intracranial hemorrhage in patients with previous stroke. 7 The Willis covered stent can be used to treat aneurysms of the supraclinoid segment of the intracranial internal carotid artery, but not other common locations such as the middle cerebral or basilar arteries because of concerns over occluding perforating or branching vessels.…”

“…Significant in-stent stenosis and delayed vessel occlusion have been reported as a complication after the use of covered stents in the cerebral circulation. 6 Double antiplatelet agents are generally used for 6 months or longer but may be associated with a small increased risk of intracranial hemorrhage in patients with previous stroke. 7…”