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

Abstract

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.

Successful Recanalization by Catheter-Directed Thrombolysis with a Continuous Intra-arterial Infusion of Low-Dose Tirofiban for Acute Carotid In-Stent Thrombosis

“…For ACIST when the stent does not fully adhere to the blood vessel, a mechanical approach should be a feasible solution to the problem. Hu W. at al [11] used a protection filter deployed at the distal part of the stent and redilation of the stent performed with a balloon. Thus, carotid revascularization was performed successfully, proven by postprocedural angiogram.…”

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

“…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 .…”

“…Several of these factors (e.g., stent under-expansion, in which the stent does not fully adhere to the blood vessel 7 or balloon bursts 11 ), plaque protrusion 4 , and vasospasm can immediately cause ACST, but if promptly treated, can be resolved without any long-term defect to the nervous system. Other factors, such as inadequate or early discontinuation of antiplatelet therapy [12][13][14] , clopidogrel resistance, and hypercoagulable state 8 , may cause ACST a few days after the CAS procedure.…”

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

“…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. ), plaque protrusion 4 , and vasospasm that might immediately lead to ACST.…”

“…According to the review of 32 cases, 10 cases were found without reporting the relevant reasons caused disease 10,[12][13][14][15][16][17][18][19] , 11 cases due to CAS procedure 6,9,[19][20][21][22] , 2 cases due to antiplatelet resistance 18,23 , 3 cases due to hypercoagulable state 4,7,22 , 4 cases due to discontinuation of antiplatelet 11,13,24,25 , 1 case due to cardiac multiple embolism 13 , and 1 case remained unclear 26 . As we mentioned previously, the ACST caused by CAS is often timely resolved and patients may have a good prognosis, and that may be the most common reason as well.…”