Rescue Revascularization Therapy With a Stent-in-Stent Technique for Acute Intracranial Internal Carotid Artery Occlusion-Case Report-

2018

Intervent Neurol

Background: Based on the results of a recent randomized controlled trial, carotid artery stenting (CAS) was regarded as a relatively safe, less invasive treatment of internal carotid artery stenosis. However, cerebral thromboembolic events are the most common complications of CAS. Especially acute stent thrombosis following CAS will be fatal without prompt diagnosis and revascularization. Case Report: We report a case of acute stent thrombosis in whom carotid revascularization was performed successfully via arterial thrombolysis and balloon postdilation. A 79-year-old man with hypertension was hospitalized for an episode of transient ischemic attack. Computed tomography angiography revealed subtotal occlusion in the left carotid artery. Aspirin (100 mg) and clopidogrel (75 mg) were administered daily for 5 days before the procedure. CAS was performed under local anesthesia. The first postprocedural angiogram showed the stent looked good. However, a repeat angiogram showed in-stent thrombosis 2 min after withdrawal of the cerebral protection filter. Interestingly, the patient presented no neurologic deficit. After an additional 2,000 U of heparin had been administered intravenously, a microcatheter (SL-14; Boston Scientific, USA) was positioned to the in-stent thrombosis. Next, a total dose of 10 mg of recombinant tissue plasminogen activator was injected into the thrombus via the microcatheter within 10 min, which led to partial recanalization with antegrade flow. However, complete occlusion of the lesion occurred 5 min later. Under the guidance of angiography roadmap, a protection filter (Emboshield NAV6; Abbott Vascular, USA) was deployed at the distal part of the stent and redilation of the stent was performed with a 5 × 30 mm balloon (Viatrac 14 Plus; Abbott Vascular) at 14 atm. Finally, carotid revascularization was performed successfully, proven by postprocedural angiogram. Conclusion: Acute carotid stent thrombosis (ACST) can have devastating effects on the survival of the patient. For ACST when the stent does not fully adhere to the blood vessel, a mechanical approach should be a feasible solution to the problem.

Section: Discussion and Literature Reviewmentioning

confidence: 73%

Acute In-Stent Thrombosis after Carotid Angioplasty and Stenting: A Case Report and Literature Review

2018

Intervent Neurol

“…Many factors cause ACST, such as inadequate or early discontinuation of antiplatelet therapy, clopidogrel resistance, hypercoagulable state, soft plaque protrusion, local vessel dissection, vasospasm, and intimal injury [7][8][9] . Also, the stent morphology plays an important role in ACST 10 .…”

Section: Discussionmentioning

confidence: 99%

“…A computed tomography (CT) angiography showed severe stenosis at the beginning of the left internal carotid artery (LICA) (Figure 1). His platelet count was 107x10 9 /L, and his coagulation function was normal. After multidisciplinary consultation, including Cardiology, Respiratory Medicine, Neurosurgery, and Anesthesiology, anesthesiologists believed that the risk of general anesthesia was greater due to poor lung function in the patient, resulting in left carotid stenting rather than endarterectomy for secondary prevention.…”

mentioning

confidence: 97%

Revascularization of Acute Stent Thrombosis after Carotid Artery Stenting in a Clopidogrel Resistance Patient

Wei

et al. 2019

Preprint

Carotid artery stenting (CAS) is an alternative strategy to prevent ischemic stroke in patients who are at high risk of surgery compared with carotid endarterectomy (CEA). Acute carotid stent thrombosis (ACST) is an extremely rare but devastating complication after CAS. Theoretically , it occurs within 30 days after CAS . There are several reasons causing ACST, such as inadequate antiplatelet therapy, early discontinuation of antiplatelet therapy, clopidogrel resistance, hypercoagulable state, local vessel dissection, vasospasm, and intimal injury. Although successful recanalization cases have been reported, there is still a lack of experience in the choice of treatment methods and the timing of ACST treatment, especially when the patient has clopidogrel resistance. Here, we report a case with successful revascularization after ACST in a patient with evidenced clopidogrel resistance, which was further confirmed by genetic testing.In this case, both thrombus aspiration and platelet glycoprotein IIb/IIIa antagonist (GPIs) were used for recanalization. In addition, we review the literature and discuss appropriate treatment strategies for this devastating and rare event.

“…There are several reasons causing ACST, such as inadequate antiplatelet therapy, early discontinuation of antiplatelet therapy, clopidogrel resistance, hypercoagulable state, soft plaque and its protrusion, local vessel dissection, vasospasm, intimal injury, and so on [6][7][8] . In one hand, a number of reasons, including cause of CAS (i.e., stent underexpansion, in which stent does not fully adhere to the blood vessel 6 , balloon burst 9 , etc.…”

Section: Discussionmentioning

confidence: 99%

Revascularization of Acute Stent Thrombosis after Carotid Artery Stenting in Clopidogrel Resistance Patient

Wei

et al. 2019

Preprint

Carotid Artery Stenting (CAS) is an alternative strategy to prevent ischemic stroke in patients who are at high-risk of surgery compared with carotid endarterectomy (CEA) .Acute carotid stent thrombosis (ACST) was extremely rare, but devastating complication after CAS. Academically, it occurred within 30 days after CAS. There are several reasons causing ACST, such as inadequate antiplatelet therapy, early discontinuation of antiplatelet therapy, clopidogrel resistance, hypercoagulable state, local vessel dissection, vasospasm, intimal injury, and so on. Although successful recanalization cases were reported, however, there is still a lack of experience in the choice of treatment methods and the timing of ACST treatment, especially when the patient has clopidogrel resistance. We are here to provide a case that successfully revascularization after ACST in patient with evidenced clopidogrel resistance, which was further confirmed by genetic testing. In our case, both thrombus aspiration and platelet glycoprotein IIb/IIIa antagonist (GPIs) were used for recanalization. Also, we review the literature and discuss appropriate treatment strategies for this deadly and rare event.