Objective: Recent studies evaluating plaque protrusion at carotid artery stenting (CAS) using optical coherence tomography showed not a few cases of plaque protrusion when using double-layer micromesh stents. We report a case of symptomatic internal carotid artery (ICA) stenosis with at-risk unstable plaques in which CAS was successfully performed using a stent-in-stent technique by the combined use of a closed-cell stent and a dual-layer micromesh stent.

Case Presentation: An 87-year-old Japanese man with dysarthria and right hemiparesis was diagnosed with atheromatous cerebral embolism caused by severe left ICA stenosis on MRI and DSA. MRI with T1-weighted black blood methods showed high intensities in the plaques of the left ICA, suggesting unstable plaque characteristics with intraplaque hemorrhage components. On day 20, CAS was performed. After the pre-stent dilation under proximal and distal protection, a Carotid WALLSTENT was placed to cover the stenotic lesion. Then, a CASPER Rx was placed from the proximal left ICA to the common carotid artery to cover the Carotid WALLSTENT. Although visible plaque debris was recognized in the aspirated blood, the debris became invisible after aspiration of 1300 mL. Postoperative angiography showed enough dilation of the left ICA, with no plaque protrusion or acute stent thrombosis. The patient had an uneventful postoperative course and was discharged without any neurological sequelae.

Conclusion: The present case suggests that the combined stent-in-stent technique using a closed-cell stent and a micromesh stent can be considered as one of the treatment strategies for preventing plaque protrusion and procedural ischemic complications in patients with high-risk carotid plaques.

Objective: Carotid artery stenting (CAS) is common procedure for carotid stenosis, but sometimes acute in-stent thrombosis or plaque protrusion after CAS leads to postoperative stroke. There are few reports of aspiration of in-stent plaque protrusion. This paper reports a case of acute in-stent mobile plaque aspirated with a distal access catheter.

Case Presentation: A 74-year-old male underwent CAS for symptomatic internal carotid artery stenosis and postoperative course was thought to be good, but in-stent mobile plaque was detected by carotid duplex at postoperative day 6. As mobile plaque is a high risk for stroke, we performed plaque aspiration with a distal access catheter, without neurological deficit or a new cerebral lesion in magnetic resonance imaging. We present a case report, including a literature review, of acute thrombosis or in-stent plaque protrusion.

Conclusion: Aspiration removal may be effective for in-stent mobile plaque, which is expected to be fragile, avoiding the disadvantages of increasing stents.