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

Abstract

Objective: Symptomatic in-stent thrombosis with or without plaque protrusion is a relatively rare but devastating complication of carotid artery stenting (CAS).
Case presentation: A 72-year-old man presented with repeated transient ischemic attacks (TIAs). Digital subtraction angiography (DSA) showed severe stenosis in the left internal carotid artery at its origin. Cervical MRI revealed carotid soft plaque. Balloon-protected CAS was planned. A self-expandable open-cell-type stent (PRECISE^TM) was successfully placed with a good angiographic result. However, he suffered a recurrent TIA several hours after the CAS procedure. Enhanced computed tomography (CT) scan revealed a contrast defect in the stent suggesting acute thrombus formation. Despite medical treatment including systemic heparinization and triple anti-platelet therapy, a follow-up ultra-sound examination showed enlargement of the thrombus in the stent. His neurological condition deteriorated and we decided to perform another stenting procedure. DSA demonstrated a significant contrast defect in the stent. A self-expandable closed-cell-type stent (Wallstent RP^TM) was successfully deployed on the inside of a PRECISE^TM stent under distal balloon protection. A satisfactory angiographic result was achieved. After the second procedure, he showed good recovery from the neurological symptoms and no more TIAs.
Conclusion: This case demonstrated the usefulness of the stent-in-stent technique for medically refractory in-stent thrombosis with or without plaque protrusion. A closed-cell-type stent would be theoretically more effective in this situation.