Saphenous vein interposition graft for recurrent carotid stenosis after prior endarterectomy and stent placement. Case report

Refractory In-stent Restenosis Following Carotid Artery Stenting: A Case Report and Review of Operative Management

In-stent restenosis following carotid artery stenting is a challenging problem that vascular surgeons will likely encounter with increasing frequency. The following describes a patient who developed progressive in-stent restenosis 3 years after carotid artery stenting, which was treated with operative therapy after failed balloon angioplasty. A review of the literature describing surgical approaches to the treatment of in-stent restenosis was also performed.

Cerebral Aneurysm Perforations during Treatment with Detachable Coils. Use of Remodelling Balloon Inflation to Achieve Hemostasis

SUMMARY

Perforation of intracranial aneurysms during endovascular treatment with platinum microcoils is a well-known and serious complication reported to occur in 2-4% of patients. Inflation of a remodelling balloon across the aneurysm neck or within the proximal parent vessel is an additional technique that theoretically might be useful to reduce flow within the aneurysm and achieve hemostasis. In the case reports that follow, we present our experience using this technique for managing intraprocedural aneurysm rupture.

Surgical removal of self-expanding stents from the carotid artery: does the type of stent make a difference?

PURPOSE

To evaluate the degree of difficulty in surgically removing 2 different stent models placed in the canine carotid artery.

METHODS

In 5 dogs, each carotid artery was stented with a braided Elgiloy self-expanding stent (BESES) on one side and a surface-spanning micro stent (SSMS) on the other. After 4 weeks, an arteriogram was obtained, and the stents were removed via direct surgical exposure. The minimum lengths of the skin incisions and arteriotomies, the ease of stent removal, and the presence of a distal intimal flap were recorded.

RESULTS

Stent deployment and removal were successful in each animal, but there was a substantial difference in the ease of removal. The BESES could be removed in a strand-by-strand fashion via a more proximal, smaller arteriotomy compared to the SSMS (8.8+/-1.3 versus 37.2+/-4.7 mm, p<0.01). Furthermore, a smaller skin incision (3.85+/-0.9 versus 9.75+/-0.5 cm, p<0.01) was required for the BESES. There was no distal flap formation following BESES removal, whereas SSMS removal produced a large distal flap in each artery (p<0.01).

CONCLUSIONS

Although rare, restenosis after stenting occurs, and surgical repair may become necessary in some patients. Each stent has inherent advantages and disadvantages, but the braided Elgiloy self-expanding stent lends itself to easier surgical removal, which may have important clinical implications, especially when used in the carotid artery.

Operative management of carotid artery in-stent restenosis: first experiences and duplex follow-up

OBJECTIVES

Carotid Artery Stenting (CAS) may be comparable to Carotid Endarterectomy (CEA) as a durable and effective procedure in stroke prevention. Concern remains about the incidence of restenosis after stenting and its management. We evaluated the surgical management of restenosis after CAS.

DESIGN

prospective study.

METHODS

between December 1997 and April 2001, 217 CAS procedures were performed in 217 patients (155 men and 62 women; age 70 years +/- 8.2). After a mean of 8 months post-stenting four patients (two symptomatic, two asymptomatic with contralateral occlusion) with severe haemodynamic in-stent restenosis (90-99%) had surgical reintervention.

RESULTS

standard CEA with removal of the stent was performed in all four patients. No major complications occurred. Intima hyperplasia showed to be the predominant mechanism leading to in-stent restenosis. All four surgically treated patients remained asymptomatic and without recurrent restenosis over a mean follow-up time of 13 months (range 3-20 months).

CONCLUSION

the optimal treatment of in-stent restenosis has yet to be defined, but standard CEA with removement of the stent appears to be feasible.

Surgical management of acute complications and critical restenosis following carotid artery stenting

Carotid artery angioplasty with stenting (CAS) is being increasingly used in the treatment of extracranial carotid artery stenosis. As in other catheter-based approaches to the treatment of arterial disease, surgical intervention may be required because of either acute complications or correct critical restenosis. We have reviewed our experience managing early complications and critical in-stent restenoses after CAS in a tertiary care university hospital and a Veterans Affairs Medical Center. During the last 5 years, 22 carotid arteries (21 patients) underwent CAS. One patient developed thrombosis and rupture of the carotid artery during stenting. Two other patients (3 arteries) developed critical restenosis within 12 months. Subsequent surgical reconstructions included an internal carotid artery (ICA)-to-external carotid artery (ECA) transposition and a common carotid artery (CCA)-to-ICA bypass with reversed saphenous vein (RSV). The patient who underwent CCA-to-ICA bypass later required subclavian-to-ICA bypass because of rapidly progressive intimal hyperplasia and subsequent occlusion of the CCA. The other patient has not had surgical repair because of his deteriorating condition and significant co-morbidities. During the same time period, two additional patients were referred from outside institutions specifically for surgical intervention after carotid stenting. One had delayed rupture of the carotid artery 1 day after stenting and underwent urgent surgical repair. Another patient had early, critical restenosis within the stent and underwent placement of a CCA-to-ICA interposition graft using RSV. Acute treatment failures after CAS can be successfully managed using standard surgical techniques. Patients who develop critical in-stent restenosis requiring surgical repair may need more challenging surgical reconstructions to maintain cerebral perfusion.

Superficial temporal artery to middle cerebral artery bypass and external carotid reconstruction for carotid restenosis after angioplasty and stent placement

The recent proliferation of endovascular treatment of carotid atherosclerotic disease will increase the number of patients who require treatment for recurrent carotid stenosis after angioplasty and stent placement. The optimal management of these patients has not yet been defined. We describe a 66-year-old woman who required 2 surgical procedures for recurrent in-stent carotid stenosis. She experienced numerous transient ischemic attacks 5 months after left extracranial internal carotid artery angioplasty and stenting for asymptomatic stenosis. Angiography showed high-grade in-stent restenosis, left intracranial carotid artery stenosis, and poor collateral flow to the left middle cerebral artery circulation. The patient underwent a superficial temporal artery to middle cerebral artery bypass, and the transient ischemic attacks resolved. Five months later, angiography showed progressive stenosis of the external carotid artery at the site of the stent. The patient underwent successful external carotid reconstruction with an on-lay patch. Extracranial-intracranial bypass grafting may be used successfully in the treatment of recurrent extracranial carotid artery stenosis after angioplasty and stent placement. Also, external carotid artery reconstruction at the site of an internal carotid artery stent can be performed safely.