Cutting balloon angioplasty for carotid in-stent restenosis: case reports and review of the literature

Cutting Balloon Angioplasty for Severe In-Stent Restenosis after Carotid Artery Stenting: Long-Term Outcomes and Review of Literature

PURPOSE

Cutting balloon-percutaneous transluminal angioplasty (CB-PTA) is a feasible treatment option for in-stent restenosis (ISR) after carotid artery stenting (CAS). However, the longterm durability and safety of CB-PTA for ISR after CAS have not been well established.

MATERIALS AND METHODS

We retrospectively reviewed medical records of patients with ISR after CAS who had been treated with CB-PTA from 2012 to 2021 in our center. Detailed information of baseline characteristics, periprocedural and long-term outcomes, and follow-up imaging was collected.

RESULTS

During 2012-2021, a total of 301 patients underwent CAS. Of which, CB-PTA was performed on 20 lesions exhibiting severe ISR in 18 patients following CAS. No patient had any history of receiving carotid endarterectomy or radiation therapy. These lesions were located at the cervical segment of the internal carotid artery (n=16), proximal external carotid artery (n=1), and distal common carotid artery (n=1). The median time interval between initial CAS and detection of ISR was 390 days (interquartile range 324-666 days). The follow-up period ranged from 9 months to 9 years with a median value of 21 months. Four patients (22.2%) were symptomatic. The average of stenotic degree before and after the procedure was 79.2% and 34.7%, respectively. Out of the 18 patients receiving CB-PTA, 16 (88.9%) did not require additional stenting, and 16 (88.9%) did not experience recurrent ISR during the follow-up period. Two patients who experienced recurrent ISR were successfully treated with CB-PTA and additional stenting. No periprocedural complication was observed in any case.

CONCLUSION

Regarding favorable periprocedural and long-term outcomes in our single-center experience, CB-PTA was a feasible and safe option for the treatment of severe ISR after CAS.

In-Stent Restenosis of Carotid and Vertebral Arteries Treated by Angioplasty Using a Cutting Balloon: A Case Report

Objective

We treated a patient with internal carotid artery and vertebral artery ostium in-stent restenosis (ISR) treated by cutting balloon (CB) angioplasty.

Case Presentation

A 79-year-old man developed dizziness and right homonymous upper quadrantanopia. On arrival, magnetic resonance imaging (MRI) revealed acute-stage brain infarction. Angiography demonstrated left internal carotid artery and vertebral artery ostium stenosis (VAOS), which was thought to be related to the infarction. We performed stenting for both lesions, but 5 months later, restenosis occurred. The patient was successfully retreated by CB angioplasty for both lesions.

Conclusion

When treating carotid or vertebral artery ISR, plain balloon (PB) and stent-in-stent (SIS) procedures may induce insufficient dilatation, and hamper re-retreatment because of neointimal hyperplasia. Using CB should be considered as an option in such cases.

Carotid endarterectomy for treatment of carotid in-stent restenosis: long-term follow-up results and surgery experiences from one single centre

Objective

Few studies have reported the surgical treatment of carotid in-stent restenosis (ISR), more data and longer follow-up are needed. We describe the surgical treatment of ISR by standard carotid endarterectomy (CEA) with stent removal, including long-term follow-up in 10 patients from our centre.

Methods

Ten patients from our centre who underwent CEA with stent removal for ISR were retrospectively analysed, including nine symptomatic and one asymptomatic ISR of at least 70% with mean age 67.3, the median time between carotid artery stenting and CEA was 17 months (range, 2–54 months).

Results

Standard CEA with stent removal was performed in all 10 patients without much technical difficulty (9 male and 1 female, mean age 67.3). Two cases were performed in hybrid operation room. There were a total of three complications that happened in three patients (30%) respectively. An asymptomatic dissecting aneurysm was formed on the petrous internal carotid artery in one patient who was followed up without intervention. In the second case, dissection occurred in the arterial wall distal to the site of the stent after stent removal revealed by intraoperative angiography, and another stent was implanted. The patient sustained temporary hypoglossal nerve dysfunction postoperatively. The third patient suffered cerebral hyperperfusion with complete recovery when discharged. No neurological complications occurred in other seven patients. After follow-up of 25 months (range, 11–54 months), one patient died of rectal cancer without ischaemic attack and restenosis 4 years postoperation; in one patient occurred recurrent symptomatic restenosis (90%) 1 year later; all other patients remained asymptomatic and without recurrent restenosis (>50%) by follow-up carotid ultrasound or CT angiography.

Conclusion

It seems that CEA with stent removal is a reasonable choice, by experienced hand, for symptomatic ISR with higher but acceptable complications. The indication of stent removal for asymptomatic ISR needs further observation.

Successful treatment of recurrent carotid in-stent restenosis and drug-eluting balloon failure with a coronary bioresorbable vascular scaffold: A case report

INTRODUCTION

Carotid in-stent restenosis is associated with substantial risk of recurrent restenosis, even after drug-eluting balloon usage.

PRESENTATION OF CASE

We hereby report the case of a patient with recurrent carotid in-stent restenosis and drug-eluting balloon failure treated with a coronary bioresorbable vascular scaffold, achieving a satisfactory acute and long-term result, as disclosed by duplex ultrasound scan performed more than 1 year after the procedure.

DISCUSSION/CONCLUSION

While awaiting for external validation, this clinical vignette supports expanding the armamentarium of endovascular specialists focusing on carotid artery disease, while providing further proof of the safety and efficacy of current bioresorbable vascular scaffolds.

Carotid artery stenting: current and emerging options

Carotid artery stenting technologies are rapidly evolving. Options for endovascular surgeons and interventionists who treat occlusive carotid disease continue to expand. We here present an update and overview of carotid stenting devices. Evidence supporting carotid stenting includes randomized controlled trials that compare endovascular stenting to open surgical endarterectomy. Carotid technologies addressed include the carotid stents themselves as well as adjunct neuroprotective devices. Aspects of stent technology include bare-metal versus covered stents, stent tapering, and free-cell area. Drug-eluting and cutting balloon indications are described. Embolization protection options and new direct carotid access strategies are reviewed. Adjunct technologies, such as intravascular ultrasound imaging and risk stratification algorithms, are discussed. Bare-metal and covered stents provide unique advantages and disadvantages. Stent tapering may allow for a more fitted contour to the caliber decrement between the common carotid and internal carotid arteries but also introduces new technical challenges. Studies regarding free-cell area are conflicting with respect to benefits and associated risk; clinical relevance of associated adverse effects associated with either type is unclear. Embolization protection strategies include distal filter protection and flow reversal. Though flow reversal was initially met with some skepticism, it has gained wider acceptance and may provide the advantage of not crossing the carotid lesion before protection is established. New direct carotid access techniques address difficult anatomy and incorporate sophisticated flow-reversal embolization protection techniques. Carotid stenting is a new and exciting field with rapidly advancing technologies. Embolization protection, low-risk deployment, and lesion assessment and stratification are active areas of research. Ample room remains for further innovations and developments.