EJVES Extra
Volume 18, Issue 5 , Pages e57-e59, November 2009

An Unusual Case of Post-stent Carotid Artery Stenosis with Successful Operative Repair: A Case Report

Department of Vascular Surgery, King's College London, Denmark Hill, London SE5 9RS, UK

Received 11 February 2009; accepted 14 July 2009. published online 01 September 2009.

Article Outline

Abstract 

We report a symptomatic internal carotid artery restenosis distal to a carotid stent in a 69-year-old man, which resulted in a stroke 6 months post-stenting. It was treated by a successful carotid endarterectomy and explantation of the stent.

Keywords: Carotid artery stent, Carotid artery atheromatous disease, Endovascular complication

 

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Introduction 

Management of carotid artery atheromatous disease includes carotid stenting (CAS).1 Two main types of stenosis are noted2 – in-stent restenosis (ISR) and the less common post-stent stenosis. Earlier studies have described repeat angioplasty to manage such cases.2 We report a case of the successful surgical management of an end-of-stent restenosis.

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Case Report 

A 69-year-old man, was admitted with a sudden onset of dysphasia and an exacerbation of his pre-existing right sided weakness. The history included a left middle cerebral artery territory infarction that occurred six months previously. A high grade ipsilateral internal carotid artery (ICA) stenosis had been confirmed as the likely embolic source and was treated by CAS 6 months ago.

A CT brain scan revealed an old left cerebral infarction but no new ischaemic or haemorrhagic features. CT angiogram and carotid/vertebral duplex scan both identified a severe (90%) stenosis of the left ICA distal to the carotid artery stent with an evident intimal flap (Figure 1, Figure 2).

After multidisciplinary discussion, it was agreed that further intervention was appropriate, and to be effected by surgical rather than endovascular means. It was assumed that the stent/plaque complex would not prove amenable to endarterectomy. Therefore, the initial intention was a left common to internal carotid bypass with exclusion of the stent and its associated stenosis. However, at surgery, there was little evidence of the expected transmural arterial inflammation, and so a tentative attempt at conventional carotid endarterectomy was undertaken. Unexpectedly, the standard plane of cleavage was preserved and carotid endarterectomy with en-bloc stent explantation proved straightforward (Fig. 3). The post-operative course was uneventful and the patient was discharged on the second post-operative day without any further neurological events.

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Discussion 

Carotid endarterectomy is the preferred method for cerebral revascularisation in both symptomatic and asymptomatic extracranial carotid artery stenosis.3, 4 The alternative, less invasive, approach of carotid artery stenting has recently emerged.1

Restenosis following CEA is a well-known complication, with reported rates of between 6% and 14%. Fortunately, only 1–5% of patients with post-CEA restenoses experience recurrent neurological symptoms.5 The variation in these figures may be because of a discrepancy in definition of restenosis with respect to both time of onset and the stenosis grade.

The experience of restenosis following CAS is more limited. Two types of restenosis predominante.2 The most common is in-stent restenosis. Lal et al6 have categorised these in-stent restenoses (ISR) according to their placement and extent in the stent.

In-stent stenosis is thought to be a consequence of neointimal hyperplasia.7 The exact pathophysiological mechanism is currently unknown, but a hyperactive immune system response with raised IL-6 and homocysteine is postulated a possibility.5

Previous authors have described both the endovascular and surgical management of in-stent restenosis. The endovascular approaches include both angioplasty alone and with restenting.6, 8, 9, 10 For in-stent stenosis, the possible surgical solutions include: common carotid to internal carotid exclusion bypass, internal carotid to external carotid transposition and CEA with explantation. The choice of operation was determined by the degree to which the stent was incorporated into the vessel wall and the neointima. Where there is minimal stent incorporation a typical endarterectomy plane can be developed between the intima and internal elastic lamina carotid endarterectomy can be conducted in the standard manner. Our initial concern that the stent would be vigorously incorporated necessitating a CCA-distal ICA bypass, proved unfounded.

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Conclusion 

As the use of carotid stents becomes more common, the vascular surgeon should be aware of the potential for restenosis both within and close to the stent. This case confirms that operative carotid endarterectomy can be a safe, effective retrieval procedure for management of carotid stent ‘end-of-stent’ stenosis.

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References 

  1. Yadav JS, Roubin AS, Iyer S, Vitek J, King P, Jordan WD. Elective stenting of the extracranial carotid arteries. Circulation. 1997;95:376–381
  2. Willfort-Ehringer A, Ahmadi R, Geschwandtner ME, Haumer M, Lang W, Minar E. Single center experience with carotid stent restenosis. J Endovasc Ther. 2002;9:299–307
  3. The North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325:445–453
  4. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study . Endarterectomy for asymptomatic carotid artery stenosis. J Am Med Assoc. 1995;273:1421–1428
  5. Lal BK. Recurrent stenosis after CEA and CAS: diagnosis and management. Semin Vasc Surg. 2007;20:259–266
  6. Lal BK, Kaperonis EA, Cuadra S, Kapadia I, Hobson RW. Patterns of in-stent restenosis after carotid artery stenting: classification and implications for long-term outcome. J Vasc Surg. 2007;46:833–840
  7. Lattimer CR, Burnand KG. Recurrent carotid stenosis after carotid endarterectomy. Br J Surg. 1997;84:1206–1219
  8. Zhou W, Lin PH, Bush RL, Peden EK, Guerrero MA, Kougias P, et al. Management of in-stent restenosis after carotid artery stenting in high-risk patients. J Vasc Surg. 2006;43:305–312
  9. Valenti D, Gaggiano A, Mazzei R, Maggio D, Ferri M, Palombo D. Management of secondary recurrent carotid stenosis following endovascular treatment: a case report. Eur J Vasc Endovasc Surg Extra. 2003;5:78–81
  10. Setacci C, De Donato G, Setacci F, Pieraccini M, Cappelli A, Trovato RA, et al. In-stent restenosis after carotid angioplasty and stenting: a challenge for the vascular surgeon. Eur J Vasc Endovasc Surg. 2005;29:601–607

PII: S1533-3167(09)00025-9

doi:10.1016/j.ejvsextra.2009.07.005

Refers to article:

  • An Unusual Case of Post-stent Carotid Artery Stenosis with Successful Operative Repair: A Case Report , 31 August 2009

    H. Mistry, A. Currie, C. Lioupis, M. Tyrrell, D. Valenti
    European Journal of Vascular & Endovascular Surgery December 2009 (Vol. 38, Issue 6, Page 780)

EJVES Extra
Volume 18, Issue 5 , Pages e57-e59, November 2009

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