Carotid Stent Thrombosis

Importance of cerebral angiography in the evaluation of delayed carotid stent thrombosis: a case report

BACKGROUND

While noninvasive imaging is typically used during the initial assessment of carotid artery disease, digital subtraction angiography remains the gold standard for evaluating carotid stent thrombosis and stenosis (Krawisz in Cardiol Clin 39:539-549, 2021). This case highlights the importance of digital subtraction angiography for assessing carotid artery stent patency in place of non-invasive imaging.

CASE PRESENTATION

We present a 61-year-old African American male patient with a history of right cervical internal carotid artery dissection that was treated with carotid artery stenting and endovascular thrombectomy, who developed recurrent right hemispheric infarcts related to delayed carotid stent thrombosis. Digital subtraction angiography found multiple filling defects consistent with extensive in-stent thrombosis not clearly observed with magnetic resonance angiography. Etiology was likely secondary to chronic antiplatelet noncompliance. Therefore, the patient was treated medically with a heparin drip, and dual antiplatelet therapy (dAPT) was restarted. At 1-month follow-up the patient did not report new motor or sensory deficits.

CONCLUSION

In the setting of delayed carotid stent thrombosis secondary to antiplatelet noncompliance, digital subtraction angiography may play an essential diagnostic role for early identification and determination of the most appropriate treatment.

Carotid endarterectomy for acute carotid thrombosis after carotid artery stenting with CASPER Rx® stent: A case report

Background

Acute carotid stent thrombosis (ACST) is a rare but devastating complication for carotid artery stenting (CAS). That requires early diagnosis and immediate treatment. Although administration of drugs or endovascular treatment is the most widely used approach for patients with ACST, there is no consensus on the standard treatment of this disease.

Case Description

The present study reports on an 80-year-old female patient with the right internal carotid artery stenosis (ICS) that had been followed up by ultrasonography for 8 years. Although the optimal medical treatment was followed, the patient's right ICS worsened, and the patient was subsequently hospitalized for CAS. On the 12^th day after CAS, left paralysis and dysarthria were observed. Head magnetic resonance imaging (MRI) showed acute obstruction of the stent and scattered cerebral infarction in the right cerebral hemisphere caused possibly by the discontinuation of temporary antiplatelet drug therapy as a means to prepare for embolectomy of the femoral artery. Stent removal and carotid endarterectomy (CEA) were selected as the appropriate treatment approach. CEA was performed with the precaution of stent removal and distal embolism, and complete recanalization was obtained. Postoperative head MRI showed no new findings of cerebral infarction, and the patients remained symptom-free after 6 months of postoperative follow-up.

Conclusion

Stent removal with CEA could be an appropriate curative option in some cases with ACST except in patients at high risk of CEA and in the chronic phase after CAS.

Acute Early Carotid Stent Thrombosis: A Case Series

BACKGROUND

Acute early carotid stent thrombosis (AcuteCST) is a rare complication after carotid artery stenting (CAS). The purpose of this retrospective study was to investigate the incidence, causes, and optimal management of AcuteCST.

METHODS

Medical records of all patients undergoing CAS between 2008 and 2016 were retrospectively reviewed. The time of thrombosis, grade of stenosis, lesion side, preprocedural and postprocedural anticoagulants, causes, symptoms, treatment, recanalization, and outcome were reviewed.

RESULTS

Overall, 674 patients were treated with CAS. Four cases of AcuteCST were identified (0.59%). In the first patient, the stent thrombosis was attributed to dissection caused by filter deployment within a distal internal carotid artery with 360° coiling. Notably, in 3 of the 4 cases of thrombosis a second overlapping stent had been deployed. In total, 41 patients of the cohort under investigation underwent overlapping stent deployment. The use of a second overlapping stent as a bail-out procedure due to dissection or malposition or due to long lesions was correlated with increased rate of thrombosis (3/41 [7.3%] vs. 1/633 [0.002%]). In 2 patients, carotid stents were thrombosed within 2 hr of the procedure. Endovascular thrombus aspiration and subsequent eversion carotid endarterectomy with stent explantation in the first patient and intrathrombus urokinase administration with thromboaspiration and additional stent placement in the second patient were followed. In the other 2 patients having their carotid stents thrombosed 3 and 4 days after the procedure, treatment with low weight molecular heparin and antiplatelet regimens was followed.

CONCLUSIONS

The use of overlapping stents in the carotid artery is a predisposing factor for AcuteCST. Prognostic factors of this potentially devastating complication are the initial clinical presentation expressing the grade of ischemic brain damage, the accurate and timely recognition of the thrombosis, and the prompt restoration of oxygenated blood flow into the viable tissue at risk of infarction.

Acute Carotid Stent Thrombosis

Acute carotid stent thrombosis (ACST) is a rare complication that can lead to dramatic and catastrophic consequences. A rapid diagnosis and prompt recanalization of the internal carotid artery are needed to minimize the ischemic insult and the reperfusion injury. We reviewed the current literature on this devastating complication of CAS with the intention of investigating the potential causative factors and to define the appropriate management. According to our study discontinuation of antiplatelet therapy, resistance to antiplatelet agents and inherent or acquired thrombotic disorders are the main causes of thrombosis. Technical intraprocedural parameters such as dissection, atheroma prolapse, kinking of the distal part of internal carotid artery and embolic protection device occlusion can also result in early carotid stent thrombosis. Rapid reperfusion ensures an improved neurological outcome and a better prognosis in the short and long term. Thrombolysis, mechanical thrombectomy or thromboaspiration in combination with drug or thrombolytic therapy, surgical therapy and re-angioplasty are treatment options that have been used with encouraging results. In conclusion, optimal perioperative antiplatelet treatment as well as technical considerations regarding the carotid artery stenting plays a determinant role.

Transient Ischemic Attack Due to Early Carotid Stent Thrombosis: Successful Rescue with Rheolytic Thrombectomy and Systemic Abciximab

Purpose:

To describe a successful neurorescue technique in a patient with generalized seizures followed by hemiparesis immediately after carotid artery stenting (CAS) for a postsurgical restenosis.

Case Report:

A 65-year-old man with a symptomatic recurrent high-grade carotid stenosis after carotid endarterectomy was treated with CAS. The procedure was complicated by sudden transient ischemic attack caused by acute carotid stent thrombosis with clot propagation into the cerebral circulation. Percutaneous mechanical thrombectomy was performed with adjunctive infusion of intravenous abciximab, resulting in complete thrombus dissolution and resolution of neurological symptoms.

Conclusions:

Access to a mechanical thrombectomy device was essential for rapid thrombus extraction, and adjunctive abciximab aided in residual clot dissolution. As a result of this combined method of clot removal, a disastrous outcome was averted.

Small in-stent Low Density on CT Angiography after Carotid Artery Stenting

SUMMARY

Carotid stenting (CAS) for carotid stenosis has developed rapidly over the last decade. Instent low density area supposed plaque protrusion or thrombus is sometimes observed on CT angiography after CAS. We evaluate the frequency and time course of the small in-stent low density after carotid artery stenting and discuss its nature and clinical significance. Between May 2005 to November 2007, 23 CASs were performed for 20 patients with carotid artery stenosis. All patients had no instent defect on digital subtraction angiography (DSA) immediately after the procedure. Followup CT angiography was performed at seven 7-10 days, 1-2 months, 6 months, and then every 6 months following CAS. We retrospectively reviewed the follow-up CT angiographic findings and clinical ischemic events. Small in-stent low density areas on CT angiography were observed in 6 lesions (26%). Four cases were added warfarin to antiplatlets and the other two cases had antiplatlets only. The in-stent low density areas were disappeared within four months after CAS and no ischemic event was observed in five patients. In the other patient, a small in-stent low density area had decreased at one month after CAS, but another small in-stent low density area appeared at five months. Subacute small in-stent low density areas were frequently observed on CT angiography following CAS, however, the low density area will disappear without clinical events by medication in most case.

Use of heparin-coated stents in neurovascular interventional procedures: preliminary experience with 10 patients

OBJECTIVE

Currently, there is minimal published data on the use of heparin-coated stents in the neurovasculature; however, these stents have a proven clinical record in the treatment of coronary disease. This article details our experience with the safety and technical aspects of stent deployment in the first 10 patients who had heparin-coated stents placed in the intracranial and cervical vasculature and the preliminary follow-up in most cases.

METHODS

We retrospectively reviewed the clinical history, intra- and periprocedural data, and imaging for the patients who received heparin-coated stents in the cervical and intracranial vasculature for cerebrovascular disease between October 2002 and October 2003.

RESULTS

Thirteen heparin-coated stents were placed in 10 patients. Seven out of the 10 patients had heparin-coated stents placed in the posterior circulation; the remaining three patients had stents placed in the anterior circulation. Four patients had stents placed intracranially. There was no acute or subacute in-stent thrombosis and no procedure-related complications. Follow-up was performed on most patients, with no clinical symptoms attributable to restenosis in any patient.

CONCLUSION

This small series suggests that heparin-coated stents are safe for use in the treatment of cervical and intracranial atherosclerotic disease. Longer-term follow-up is needed to study the heparin coating effect on in-stent restenosis rates and to assess the long-term durability and clinical efficacy of this stent. The use of drug-coated stents in the cerebrovascular circulation is an area that warrants further investigation.

The Role of Antiplatelet Therapy in Carotid Stenting for Ischemic Stroke Prevention

Background and Purpose— Carotid angioplasty and stenting (CAS) is a minimally invasive revascularization procedure that has become a popular and acceptable treatment option in the United States for high surgical risk patients with internal carotid artery atherosclerosis. It is effective and has an acceptable risk profile, but ischemic complications caused by distal embolization and underlying atherothrombosis persist.

Summary of Review— Atherothrombosis is the pathological process that is frequently implicated as the underlying cause of stroke, transient ischemic attacks, and most other ischemic vascular disease. Critical steps in the development of occlusive episodes are the disruption of atherosclerotic plaque and subsequent formation of a platelet-rich mural thrombus. Vascular injury as a result of CAS or any other percutaneous intervention triggers platelet adhesion, activation, and aggregation, resulting in the formation of a mural thrombosis. This risk, in addition to the potential risk of embolization to distal sites, provides a rationale for early antiplatelet therapy with CAS. The risk of late stent (>30 days after stenting) thrombosis in some patients, particularly those receiving drug-eluting stents, provides a rationale for prolonged antiplatelet prophylaxis as well as for prophylaxis against late atherothrombotic events. Because of the systemic and progressive nature of atherothrombosis, protection against ischemic vascular events in other arterial beds expands the benefits of long-term antiplatelet therapy.

Conclusions— As clinical experience with CAS increases, it is likely that it will be used more frequently for patients with occlusive carotid disease. In addition, adjunct antiplatelet therapy will play a key role in the continued development of CAS.

Complications associated with stenting for cerebral arteries

SUMMARY

We have experienced total 116 stenting for 102 of cranio-cephalic arteries and 14 of intracranial arteries including occlusive cerebrovascular diseases, aneurysms, and fistulas.Ten complications were encountered. Three were ischemic complication, four stent migration, two restenosis, and one aneurysmal perforation during coiling across the stent strut. The mechanism and preventive method of these complications were discussed in this paper.

Rheolytic Thrombectomy of Acute Stent Thrombosis of Cervical Vertebral Artery

A new Xpeedior rheolytic thrombectomy catheter has been successfully used to extract thrombus from an acutely thrombosed vertebral artery stent without apparent distal embolism. The ease of use and the speed of thrombectomy suggest that this system may be useful for the treatment of acute ischemic stroke.