Recurrent Subacute In-stent Restenosis After Carotid Artery Stenting due to Plaque Protrusion -Case Report-

Abstract

A 70-year-old male presented with transient ischemic attacks manifesting as right hemiparesis and motor aphasia due to severe left cervical internal carotid artery stenosis. Carotid artery stenting (CAS) using a flow-reversal system was performed without complications. However, the patient exhibited transient right hemiparesis and motor aphasia 10 days after CAS. Emergent angiography demonstrated in-stent restenosis. In-stent percutaneous transluminal angioplasty and CAS were performed successfully using a distal protection system. However, duplex ultrasound scanning revealed progressive in-stent restenosis, 3 and 6 days after the re-treatment. Emergent angiography again demonstrated in-stent restenosis. Urgent stent removal and carotid endarterectomy were performed. Plaque had prolapsed through the stent. Histological examination revealed that the specimen was mainly plaque consisting of cholesterol crystals and macrophages. The patient was able to return to independent life without neurological deficit. Repeated endovascular surgery with appropriate antiplatelet and anticoagulation therapy should be attempted initially to treat in-stent restenosis. Endarterectomy with stent removal should be considered as a rescue option, especially if plaque protrusion is identified.

Treatment Strategy for Bilateral Carotid Stenosis: 2 Cases of Carotid Endarterectomy for the Symptomatic Side Followed by Carotid Stenting

“…Despite neurological-protections during the procedure, there have been several reports about delayed plaque protrusion after CAS, especially in the patients with carotid vulnerable plaque 14,20,21 .…”

Evaluation and Management of In-stent Low-density Area on CTA after Carotid Artery Stenting at Subacute Phase

“…However, there are many case reports of the appearance of serious ischemic symptoms in the subacute phase after CAS or additional revascularization needed due to repeated ischemic attacks. [9][10][11][12][13][16][17][18][19][20] LDAs on CTA in the subacute phase may be associated with these ischemic complications. Appropriate treatment based on early detection of LDA on CTA might decrease the incidence of perioperative complications, consequently improving the results of CAS.…”

“…[4][5][6][7][8][9][10][11][12][13] In a review of stent-related thrombosis after CAS, Moulakakis et al emphasized that antiplatelet drugs were important for its prevention. They reported that etiological factors for thrombus formation included insufficient administration of antiplatelet drugs, drug resistance, inherent or acquired thrombotic disorders including cancer, and discontinuation of antiplatelet drugs.…”

“…2,3) Several studies reported that an in-stent low-density area (LDA) was often observed on CTA in the subacute phase after CAS, and that the extent of most LDAs was reduced with medication. [4][5][6][7][8] On the other hand, some studies reported ischemic complications in the subacute phase of CAS 6,[8][9][10][11][12][13] as an important issue.…”

Evaluation of Plaque Protrusion Following Carotid Artery Stenting Using 3D-rotational Angiography

“…On the other hand, delayed cerebral infarction, occurring within a few days after the procedure, is still observed with a fixed probability, remaining one of the current problems with CAS to be addressed. 6,7) Although plaque protrusion is suggested to be a primary cause of delayed cerebral infarction, there remains no established preventive measure and at present, early detection is considered important. 6-9) Shinozaki et al 2) compared plaque protrusion rates of detection between angiography and IVUS immediately after CAS in 77 consecutive patients, reporting that the detection rate was 2.6% by angiography alone, but 7.8% by IVUS, suggesting usefulness of IVUS.…”