Stent-in-stent treatment for acute in-stent thrombosis after carotid artery stenting: A case report

●Abstract● Objective: Symptomatic in-stent thrombosis with or without plaque protrusion is a relatively rare but devastating complication of carotid artery stenting CAS . Case presentation: A -year-old man presented with repeated transient ischemic attacks TIAs . Digital subtraction angiography DSA showed severe stenosis in the left internal carotid artery at its origin. Cervical MRI revealed carotid soft plaque. Balloon-protected CAS was planned. A self-expandable opencell-type stent PRECISETM was successfully placed with a good angiographic result. However, he suffered a recurrent TIA several hours after the CAS procedure. Enhanced computed tomography CT scan revealed a contrast defect in the stent suggesting acute thrombus formation. Despite medical treatment including systemic heparinization and triple anti-platelet therapy, a follow-up ultra-sound examination showed enlargement of the thrombus in the stent. His neurological condition deteriorated and we decided to perform another stenting procedure. DSA demonstrated a signifi cant contrast defect in the stent. A self-expandable closed-cell-type stent Wallstent RPTM was successfully deployed on the inside of a PRECISETM stent under distal balloon protection. A satisfactory angiographic result was achieved. After the second procedure, he showed good recovery from the neurological symptoms and no more TIAs. Conclusion: This case demonstrated the usefulness of the stent-in-stent technique for medically refractory in-stent thrombosis with or without plaque protrusion. A closed-cell-type stent would be theoretically more eff ective in this situation. ●Key Words● balloon protection, closed cell design stent, plaque MRI MPRAGE , stent in stent, stent thrombosis