Journal of Invasive Cardiology

ABSTRACT: Carotid endarterectomy in the presence of an occluded contralateral artery is associated with a high risk of perioperative stroke. Carotid stenting with neuroprotection devices has emerged as a safe procedure for revascularization in this circumstance. We performed high-risk carotid angioplasty in a patient with a history of recurrent transient ischemic attacks and 90% stenosis of left internal carotid artery with other occluded cerebral vessels. The final follow-up angiogram revealed thrombotic obstruction of the stent without any evidence of vasospasm, stent deformation or dissection. Direct thrombosuction was performed with the guiding sheath. Multiple suction passes yielded complete restoration of vascular patency and intracranial flows. A control angiogram performed 10 days later revealed no residual stenosis or thrombus. Thrombosuction using a guiding sheath leads to rapid revascularization in a patient with acute carotid stent thrombosis.

J INVASIVE CARDIOL 2010;22:E144–E146

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Atherosclerosis of the carotid artery is an important cause of stroke, with a reported incidence of 5–7% per year in patients with a > 70% stenosis of the carotid arteries.¹ Carotid endarterectomy is regarded as the gold-standard therapy for primary and secondary prevention of stroke. However, carotid endarterectomy in the presence of an occluded contralateral artery has been associated with a high risk of perioperative stroke (5.1–14.3%). This is mainly due to reduced collateral circulation during carotid clamping or cerebral hemorrhage secondary to the hyperperfusion syndrome.^2,3
Carotid stenting with neuroprotection devices has emerged as a safe procedure for carotid revascularization.⁴ It may be an attractive alternative to surgical carotid endarterectomy, especially when the surgical risk is too high. The major periprocedural complications during carotid stent placement include transient or permanent neurologic deficit due to distal thrombus embolization and, rarely, acute stent thrombosis. A well-established antithrombotic regimen and use of distal embolic protection device may help in overcoming these complications.
We report a case of acute stent thrombosis during filter-protected carotid stent placement despite combined antiplatelet and antithrombotic therapy. We also discuss the management issues involved in such a case.