Carotid stenting for carotid restenosis after carotid endartectomy and carotid stenting

A 61-yr. old female presented with a left cerebral TIA manifested by right arm weakness. Her comorbidities included smoking, lower extremity vascular disease, and hypertension. Duplex imaging confirmed severe left ICA stenosis (greater than 80%). She underwent an uncomplicated eversion carotid endarterectomy.

One year later, surveillance duplex imaging detected a greater than 80% carotid restenosis at the CCA-ICA junction (Figure 1). A decision was made to offer her a carotid stent with distal protection.

A carotid angiogram confirmed the presence of the carotid stenosis and using a 0.014 system with a distal protection device, a 6x30mm self-expanding stent was placed (Figure 2). The patient tolerated the procedure well and made an uneventful recovery. Six months later, she developed a proximal in-stent restenosis (greater than 80%), identified by Duplex imaging (Figure 3).

A carotid angiogram confirmed the presence of the carotid restenosis and using a 0.014 system with a distal protection device, a second 6x30mm self expanding stent was deployed proximally in the common carotid artery and overlapped the previously placed stent (Figure 4). The patient made an uneventful recovery from this stent placement. At 3 months follow-up, she remains stenosis free

Fig 1. Duplex ultrasound of the left carotid bulb showing focal restensosis in the endarterectomy area.

Fig 2. The patient underwent a carotid angiogram with selective catheterization of the left internal carotid and deployment of a 6mm stent, which was subsequently molded by a 6mm balloon after deployment. The intervention was performed in the presence of a distal protection device. Selective carotid angiogram before (A) and after intervention (B). The distal protection device is shown in C and the stent in D.

Fig 3. The patient developed recurrent stenosis at the proximal stent 6 months after the intervention with a peak systolic velocity of 360 cm/s.

Fig 4. The patient underwent a second carotid angiogram with selective catheterization of the left internal carotid and deployment of a 6mm stent in proximal carotid and overlapping the original stent. Selective carotid angiogram before (A) and after intervention (C). The arrow indicates the recurrent stenosis.