Stent-in-stent treatment for acute in-stent thrombosis after carotid artery stenting: a case report

Takasugi, Yuji; Sugiu, Kenji; Hiramatsu, Masafumi; Ohkuma, Yu; Itami, Hisakazu; Hishikawa, Tomohito; Tokunaga, Koji; Date, Isao

doi:10.5797/jnet.6.181

Cited by 3 publications

(5 citation statements)

References 14 publications

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“…Even with useful articles, [1][2][3][4][5][6][7]9,10 the limitations of our report come from it being an observation of only a single case; however, the usefulness of anticoagulation treatment was clearly demonstrated in the current case.…”

Section: Discussionmentioning

confidence: 81%

“…In contrast, in a similar case report, a continuous heparin infusion was performed to increase the activated clotting time (ACT) to twice that at baseline with a TAPT combination for in-stent thrombosis after CAS, but in that case, the thrombus showed increased resistance to strong antithrombotic therapy and a second CAS was performed. 5 APTT accurately reflects the heparin concentration and inhibition of Xa activity. However, decisions to adjust heparin therapy based on ACT results differed from decisions based on APTT results more than one-third of the time.…”

Section: Discussionmentioning

confidence: 99%

“…However, decisions to adjust heparin therapy based on ACT results differed from decisions based on APTT results more than one-third of the time. 14 Therefore, in the case 5 where ACT was used, there is a possibility that the ideal heparin dose adjustment was not achieved. We believe that thrombin could be suppressed safely and strongly by measuring APTT daily in the laboratory and strictly controlling it within the range of 50 to 65 seconds.…”

Section: Discussionmentioning

confidence: 99%

“…There has been no definitive treatment established for in-stent thrombosis, although there are reports of strengthening antithrombotic therapy, thrombolysis, PTA, percutaneous mechanical thrombectomy, thromboaspiration, re-stenting, and stent withdrawal with CEA. [1][2][3][4][5][6][7][8][9][10] Moulakakis et al reviewed and proposed an algorithm for management of acute carotid stent thrombosis. 3 They proposed percutaneous mechanical thrombectomy, thromboaspiration, and thrombolysis, using thrombolysis AE GP 2b/3a receptor inhibitors or surgical exploration for postprocedural stent thrombosis, and only surgical exploration for refractory thrombus.…”

Section: Discussionmentioning

confidence: 99%

“…In-stent thrombosis has been reported as a rare complication after carotid artery stenting (CAS). [1][2][3][4][5][6][7] It occurs only with a probability of 1% or less, but it could lead to serious outcomes. 1,2 We report a case in which anticoagulant therapy management was useful for a recurrent in-stent thrombosis after CAS.…”

Section: Objectivementioning

confidence: 99%

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Anticoagulant therapy for recurrent in-stent thrombosis following carotid artery stenting: A case report

et al. 2017

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We report a case in which strict anticoagulant therapy management was useful for a recurrent in-stent thrombosis after carotid artery stenting (CAS). An 84-year-old man presented with cognitive decline that progressed rapidly over two months. Head magnetic resonance imaging showed an acute-stage infarct occurring frequently in the right cerebral hemisphere, and he underwent hospitalization and treatment. On neck magnetic resonance angiography (MRA), severe stenosis was found at the origin of the right internal carotid artery. Since he took aspirin, clopidogrel, and a statin after placement of an indwelling coronary stent, we treated him by adding argatroban and edaravone drip therapy to his existing medication. CAS was performed on day 15 of the hospitalization. A small in-stent thrombosis with plaque protrusion was observed on a carotid sonogram performed at the second day after CAS, and re-examination at the seventh day confirmed enlargement of the lesion and an increase in peak systolic velocity; thus, a second CAS procedure was performed on the same day. After the second CAS, oral cilostazol was added for triple antiplatelet therapy (TAPT), but as the in-stent thrombosis increased further, we started a continuous infusion of heparin with the goal of an activated partial thromboplastin time (APTT) of 50 to 65 seconds. After starting heparin, the lesion did not progress; after 14 days of continuous heparin infusion, the patient was switched to TAPT, and regression of the plaque was confirmed. This case demonstrated to us that controlled anticoagulation therapy can be an effective treatment for cases in which a thrombus recurs within a stent after CAS.

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Section: Discussionmentioning

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Objectivementioning

confidence: 99%

See 3 more Smart Citations

Anticoagulant therapy for recurrent in-stent thrombosis following carotid artery stenting: A case report

et al. 2017

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Mobile thrombus developing in a stent at a left ICA stenotic lesion demonstrated by carotid color flow ultrasonography after implantation with a second stent to treat left vertebral stenosis: case report

Ito

Hatake

et al. 2016

Neurosonalogy

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A 60-year-old Japanese man who had undergone stent treatment for stenosis of the left carotid artery received another stent 5 months later to treat a stenotic region of the left vertebral arterial origin. Color flow ultrasonography of the carotid artery before the second stenting procedure revealed good blood flow without any defects in the previous stent. However, the day after implantation of the vertebral arterial stent, carotid color flow ultrasonography identified a new low-echoic mobile structure at the left carotid stent. This structure was diagnosed as thrombus after showing a marked decrease in size after starting anticoagulant therapy. We speculate that the coagulation system, promoted by stent implantation at the vertebral arterial origin, contributed to thrombus formation in the stent at the left carotid artery. Carotid color flow ultrasonography was helpful for detecting lowechoic mobile thrombus in a carotid stent in the present case, and may prove useful for similar future cases.

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Importance of Predilatation for CAS: Two Patients for Whom Balloons Were Mis-selected

Matsushita

Sogabe

Suzue

et al. 2018

JNET

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Objective:We report two patients for whom balloons for carotid artery stenting (CAS) were mis-selected, and review balloon selection for CAS and the purpose of predilatation.Case Presentations: Case 1: A 73-year-old man developed amaurosis fugax on his right eye. An unstable, plaqueabundant stenotic lesion of the right internal carotid artery with calcification was detected. Under flow reversal, a Carotid WALLSTENT 8 mm × 29 mm was inserted, and postdilatation was performed using a Jackal 4.5 mm × 30 mm until a nominal pressure was achieved. In-stent plaque protrusion was noted. A Carotid WALLSTENT 8 mm × 21 mm was overlapped, and the procedure was completed. Subacute thrombosis (SAT) with North American Symptomatic Carotid Endarterectomy Trial (NASCET) 40% restenosis was observed 5 days after CAS. Anticoagulant therapy gradually reduced SAT.Case 2: An 83-year-old woman presented an asymptomatic acute phase ischemic lesion in left cerebral hemisphere by scheduled MRI as a follow-up study of medical checkup. An irregular, plaque-abundant, markedly stenotic lesion of the left internal carotid artery with calcification was detected. Under flow reversal, predilatation was performed using a Sterling 3 mm × 40 mm (Boston Scientific, Marlborough, MA, USA) until a nominal pressure was achieved, and a PRECISE 9 mm × 40 mm (Cardinal Health, Inc., Dublin, OH, USA) was inserted. It was impossible to pass an Aviator 4 mm x 30 mm (Cardinal Health, Inc.) for postdilatation through the site of stenosis, and a Gateway 2.5 mm × 12 mm (Stryker, Kalamazoo, MI, USA) and Jackal 4.5 mm × 30 mm (Kaneka Medix Corp., Osaka, Japan) were used. Dilatation was achieved. Conclusion:To improve the results of CAS, it is important to establish the purpose of balloon dilatation and select a balloon in accordance with its purpose, as indicated for the selection of embolic protection devices (EPDs) and stents.

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Stent-in-stent treatment for acute in-stent thrombosis after carotid artery stenting: a case report

Cited by 3 publications

References 14 publications

Anticoagulant therapy for recurrent in-stent thrombosis following carotid artery stenting: A case report

Anticoagulant therapy for recurrent in-stent thrombosis following carotid artery stenting: A case report

Mobile thrombus developing in a stent at a left ICA stenotic lesion demonstrated by carotid color flow ultrasonography after implantation with a second stent to treat left vertebral stenosis: case report

Importance of Predilatation for CAS: Two Patients for Whom Balloons Were Mis-selected

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