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Delayed Carotid Wallstent Shortening Resulting in Restenosis Following Successful Carotid Artery Angioplasty and Stenting

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Seok-Mann Yoon at Soonchunhyang University
Seok-Mann Yoon
Kwang Wook Jo at Catholic University of Korea
Kwang Wook Jo
Min Woo Baik
Min Woo Baik
Min Woo Baik
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Young Woo Kim
Young Woo Kim
Young Woo Kim
  • This person is not on ResearchGate, or hasn't claimed this research yet.
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Abstract

Carotid angioplasty and stenting (CAS) for carotid stenosis has been increasingly used as an alternative treatment in patients not eligible for surgery. Even though CAS can be performed relatively simply in many cases, various complications can occur. We report four cases of CAS using the Carotid Wallstent, which were complicated by delayed shortening of the stent, resulting in restenosis after successful CAS.
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Delayed Carotid Wallstent Shortening Resulting in Restenosis Following Successful Carotid Artery Angioplasty and Stenti
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... Early shortening of CAS is a rare and unexpected complication. There were only a few case reports related to carotid stent shortening in patients with severe carotid stenosis (3)(4)(5)(6)(7)(8). Most cases reported delayed onset carotid stent shortening except for one case report (3). ...
... Most cases reported delayed onset carotid stent shortening except for one case report (3). Previous reports have suggested high-grade stenosis degree and a closed-cell type stent as potential risk factors (3)(4)(5)(6). Carotid stenosis related to atherosclerosis is associated with local intimal thickening of the arterial wall, plaque formation, and growth (9). Therefore, we can speculate that the arterial wall in high-grade carotid stenosis can be more rigid than a normal arterial wall. ...
Case report: Early carotid stent shortening in patient with radiation-induced carotid stenosis
Article
Full-text available
  • May 2023
Carotid artery stenting (CAS) for carotid stenosis has been widely used as an alternative treatment in patients not eligible for surgery. The shortening of a carotid stent rarely occurs. We report a case of early shortening of CAS in a patient with radiation-induced carotid stenosis and discuss the potential pathophysiology and strategies for prevention. This case presents a 67-year-old man who underwent radiotherapy for oral cavity squamous cell carcinoma 7 years ago and subsequently developed severe stenosis in the left proximal internal carotid artery. The patient underwent CAS for symptomatic severe carotid stenosis. Follow-up CT angiography revealed shortening of the carotid stent, and additional carotid stenting was performed. We speculate that the possible mechanism of early complication of CAS could be slippage and shortening of the stent due to weak anchoring between the stent strut and the fibrotic arterial wall in radiation-induced carotid stenosis.
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... 2,4 However, disadvantages and intraoperative complications during CAS related to the Carotid Wallstent were reported such as shortening of the stent during deployment in the targeted lesion. 5,6 Other physiological intraoperative complications include asystole, bradycardia, hypotension, and cerebral infarction, while mechanical complications such as vascular injuries like vasospasm and arterial dissection can occur due to mechanical stress from devices deployed intraarterially. 5 To the best of our knowledge, however, little has been documented concerning intraoperative complications related to the Carotid Wallstent. ...
Case Report An extremely rare complication during carotid artery stenting using a Wallstent: Migration of a stent holder of a Carotid Wallstent
Article
  • Jun 2024
Background: Carotid artery stenting (CAS) is an established treatment for internal carotid artery stenosis (ICS). The Carotid Wallstent is commonly used as a stent device in CAS procedures. Rare complications associated with the use of the Carotid Wallstent in CAS procedures include delayed shortening and incomplete stent expansion due to displacement of a marker ring. However, there have been no previous reports of a stent holder becoming unpredictably detached from a Carotid Wallstent during a procedure, requiring the additional deployment of another Carotid Wallstent. Case presentation: The case of a 72-year-old man with progressive ICS is described. Since the ICS was resistant to medical treatment, CAS was planned to prevent ischemic events. During the procedure, a Mo.Ma Ultra and a carotid guardwire were used for proximal and distal protection, respectively. Following the introduction of those protective devices, a Carotid Wallstent was deployed at the stenotic lesion of the ICS. After the deployment of the Carotid Wallstent, a stent holder unpredictably detached was identified in the lumen of the Carotid Wallstent. Since it was impossible to mechanically retrieve the detached stent holder, another Carotid Wallstent was deployed to trap the substance. Postoperatively, the substance was identified as a stent holder of the first Carotid Wallstent. Conclusion: This is the first report of an extremely rare complication concerning a Carotid Wallstent in CAS.
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... We had expected some shortening of the stent, but we did not administer any additional treatment to prevent it because the stent was covering the lesion well at the time of the operation. 21) We expect that, in future cases, a two-stent technique could be used to prevent such recurrence. Several studies have shown that restriction of the aneurysmal flow is more complete if the ratio of the effective mesh area to the total surface of the stent is small, regardless of the aneurysm size. ...
Stent-assisted Coil Embolization to Treat Extracranial Carotid Artery Aneurysm 13 Years after Endarterectomy: A Case Report
Article
Full-text available
  • Dec 2019
Development of extracranial carotid artery aneurysm (ECCA) after carotid endarterectomy (CEA) is a rare complication, occurring in connection with <1% of all CEAs. The main causes are infection, suture failure, and degeneration of arterial wall or patch. The traditional treatment has been operative repair, which can present a significant technical challenge owing to reoperative neck inflammation and potential cranial nerve injuries. Here, we report a case of successful stent-assisted coil embolization for right noninfectious ECCA. A 63-year-old female was admitted to our hospital for a 3-cm pulsating mass in her right midneck. Doppler examination and digital subtraction angiography revealed a large (15 mm) ECCA at the right common carotid artery (CCA). Thirteen years earlier, eversion CEA with patch angioplasty and abbreviation of the internal carotid artery (ICA) had been performed for a symptomatic 80% diameter stenosis with transient ischemic attack at another hospital. As the patient refused blood transfusion for religious reasons, we treated her with stent-assisted coil embolization, which achieved nearly complete obliteration of the aneurysm while preserving the parent artery patency. Three months after initial treatment, ultrasound revealed complete occlusion of the ECCA, but also showed stent shortening. Hence, we performed an additional stent placement so as to overlap the previous stent by 2.5 cm. Six months after initial treatment, carotid duplex ultrasound confirmed a good outcome. This procedure is an excellent choice for high-risk patients, and a larger case series is needed to establish this technique as the treatment of choice for ECCAs.
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... Also, most of the patients presented in this study were implanted with Wallstents™, an older device that is known to get shorter when deployed (stent retraction), sometimes months after implantation [38,39]. This was identified as the cause for recurrences in four of our patients. ...
Percutaneous endovascular management of chronic superior vena cava syndrome of benign causes : long-term follow-up
Article
  • Apr 2016
Background The vast majority of superior vena cava (SVC) syndromes are of malignant causes, but with growing use of indwelling central catheters and implanted cardiac devices, benign SVC syndromes are becoming more frequent. The main objective of this study is to evaluate long term outcome in patients treated for benign SVC syndrome by endovascular techniques. Methods Forty-four patients, 26 men and 18 women, mean age 56, treated for benign SVC syndrome using endovascular techniques between 2002 and 2015 were included. Type of obstruction was classified according to the site of disease and degree of occlusion. Complications and recurrence of symptoms were analyzed. ResultsTechnical and clinical success were achieved in all but one patient. Four patients (9 %) were treated by angioplasty alone and 40 (91 %) required stent implantation. Mean clinical follow-up was 1275 days. Nine patients had at least one episode of recurrence after a mean of 385 days. Four minor and two major complications were reported. Conclusion Percutaneous endovascular techniques to treat benign SVC syndrome are safe with good long term patency. Recurrence of symptoms can easily be addressed by repeat procedure. Key Points• Malposition of indwelling central catheter can cause superior vena cava obstruction.• Image-guided catheter placement helps prevent superior vena cava obstruction.• Imaging and superior vena cava obstruction classification allows adequate procedure planning.• Endovascular techniques are safe and effective for superior vena cava syndrome treatment.
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... Restenosis has reportedly occurred when stents deployed in stenotic sites shifted as a result of stent shortening. 37 However, our pooled results may indicate that cilostazol's beneficial effect could perhaps outweigh the negative effect of a closed-cell stent. ...
Meta-Analysis of Studies Evaluating the Effect of Cilostazol on Major Outcomes After Carotid Stenting
Article
  • Dec 2015
  • J ENDOVASC THER
Purpose: To evaluate the effect of cilostazol on major outcomes after carotid artery stenting (CAS). Methods: A systematic literature review was conducted conforming to established criteria in order to identify articles published prior to May 2015 evaluating major post-CAS outcomes in patients treated with cilostazol vs patients not treated with cilostazol. Major outcomes included in-stent restenosis (ISR) within the observation period, the revascularization rate, major/minor bleeding, and the myocardial infarction/stroke/death rate (MI/stroke/death) at 30 days and within the observation period. Data were pooled for all studies containing adequate data for each outcome investigated; effect estimates are presented as the odds ratios (ORs) and 95 confidence intervals (CI). Results: Overall, 7 studies pertaining to 1297 patients were eligible. Heterogeneity was low among studies so a fixed-effect analysis was conducted. Six studies (n=1233) were compared for the ISR endpoint, showing a significantly lower ISR rate with cilostazol treatment after a mean follow-up of 20 months (OR 0.158, 95% CI 0.072 to 0.349, p<0.001). Five studies (n=649) were compared regarding 30-day MI/stroke/death (OR 0.724, 95% CI 0.293 to 1.789, p=0.484) and 3 studies (n=1076) were analyzed regarding MI/stroke/death within the entire follow-up period (OR 0.768, 95% CI 0.477 to 1.236, p=0.276); no significant difference was found between the groups. Data on bleeding rates and revascularization rates post ISR were inadequate to conduct further analysis. Conclusion: Cilostazol seems to decrease total ISR rates in patients undergoing CAS without affecting MI/stroke/death events, both in the early and late settings.
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Carotid Stent: Device-Specific Complications With the Wallstent
Chapter
  • Jan 2022
The carotid Wallstent is one of the most used stents in the endovascular treatment of carotid stenosis, because its closed cell design means that it is adequate for both stable uncomplicated plaques and dishomogenous stenosis. The drawback of its versatility is reduced conformability caused by the rigidity of the device, which also leads to difficult positioning in tortuous vessels. In cases of very tight stenosis or excessive tortuosity of the vessel, the radial forces of the stent struts may determine slipping of the stent either proximally or distally to the target zone, even at late follow-up. Complications from the carotid Wallstent (Boston Scientific, Marlborough, MA) are rare, with few cases of asymptomatic occlusion or significant restenosis reported in the literature. Kinking of the distal internal carotid artery is also possible because of the rigidity of the device. Carotid Wallstents behave therefore suboptimally in very tortuous vessels. The length of the stent should be limited to a minimum in tortuous or angulated vessels, but should be calculated considering the shortening of the stent in its wider proximal end. If the shortening is greater than expected, an adjunctive proximal stent may be added because proximal plaque coverage is essential for satisfactory long-term results. Distal significant late restenosis may be successfully treated with distal stent extension, paying attention not to cause further distal kinking. Surgical stent removal and complete carotid endarterectomy may be necessary only exceptionally.
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Endovascular treatment of the vertebral artery origin stenosis by using the closed-cell, self-expandable Carotid Wallstent
Article
  • Jun 2020
Background Endovascular treatment has been considered a good alternative to surgery for symptomatic vertebral artery origin stenosis (VAOS) due to the high risk of morbidity associated with surgery. The purpose of this study was to evaluate the feasibility and efficacy of insertion of the closed-cell, self-expandable Carotid Wallstent for the treatment of VAOS. Methods The records of 72 patients with VAOS refractory to adequate medication who were treated by endovascular treatment with the Carotid Wallstent from December 2006 to November 2018 were retrospectively evaluated. Results Of the 72 patients, 43 presented with transient ischemic attacks. Forty-seven patients (65.3%) manifested other brachiocephalic stenoses; of these, 40 patients had occlusion, hypoplasia, or stenosis of the contralateral vertebral artery. Overall technical success (defined as 20% or less residual stenosis) was 100%. Procedure-related complications ( n = 8, 11.1%) included sudden asystole ( n = 1), acute in-stent thrombosis ( n = 3), minor stroke ( n = 3), and stent shortening ( n = 1). All complications were resolved without permanent neurological deficit. Angiographic follow-up (mean, 13.0 months) was achieved in 49 patients and revealed in-stent restenosis in 1 patient (2.0%) and stent malposition by shortening in 2 patients (4.1%). Follow-up records were available in 57 patients (mean 15.6 months). Three of the 57 patients ( n = 3, 5.3%) had recurrent symptoms of vertebrobasilar ischemia and none was retreated. Conclusions Endovascular treatment of symptomatic VAOS using the closed-cell, self-expandable Carotid Wallstent is technically feasible and effective in alleviating patient symptoms and for improving vertebrobasilar blood flow.
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Safety and efficacy of an open-cell stent and double-balloon protection for unstable plaques: analysis of 184 consecutive carotid artery stentings
Article
  • Nov 2019
Introduction In our institute, most cases of carotid artery stenosis are treated by carotid artery stenting (CAS) with an open-cell stent and double-balloon protection, even if plaques are unstable. This study was performed to examine the outcome of CAS with an open-cell stent and double-balloon protection for unstable plaques. Methods A total of 184 CAS procedures in our institute between October 2010 and February 2018 were assessed. Ultrasonography findings of low-echo plaques, plaque ulceration, or both were defined as unstable plaques. A plaque-to-muscle ratio (PMR) of >1.8 on T1-weighted black blood imaging using spin-echo was also defined as an unstable plaque. Seventy-four unstable plaques on ultrasonography and 86 unstable plaques evaluated by PMR were included. Open-cell stents and double-balloon protection (proximal balloon protection during lesion crossing and distal balloon protection after lesion crossing) were used in all cases. Results On ultrasonography, perioperative asymptomatic thromboembolization was significantly more frequent in the unstable plaque group (39/74, 52.7%) than in the stable plaque group (41/110, 37.3%, p=0.0384). Asymptomatic thromboembolization was also significantly more frequent in the PMR >1.8 group (44/86, 51.2%) than in the PMR <1.8 group (36/98, 36.7%, p=0.0489). However, symptomatic thromboembolization was rare (n=5, 2.7%), and all of these patients had minor stroke. During the 4-year follow-up, the risk of ipsilateral stroke was 0.28% and 0.27% per year in patients with symptomatic and asymptomatic lesions, respectively. Conclusions The outcomes of CAS with an open-cell stent and double-balloon protection are acceptable. This method is effective and safe, even if carotid artery stenosis comprises unstable plaques.
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Preliminary Report of Carotid Artery Stenting Using a Tapered Stent
Article
Full-text available
  • Jan 2011
To analyze the results of carotid artery stenting using a tapered stent and to evaluate the effectiveness of the tapered stent compared to previously reported studies using non-tapered stents.
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A case of carotid artery stenting with stent migration into the common carotid artery due to shortening of the stent using Carotid Wallstent: Case report
Article
Full-text available
  • Apr 2012
Objective: A case of carotid artery stenosis treated with carotid artery stenting (CAS) using the Carotid Wallstent, in which the stent covering the internal carotid artery (ICA) migrated into the common carotid artery (CCA) due to shortening, is reported. Case presentation: A 74-year-old man with asymptomatic carotid artery stenosis (the diameters of the ICA and CCA: 6.5mm and 10.3mm, respectively) was treated with CAS using the Carotid Wallstent and FilterWire EZ. The stent was deployed to cover the distal ICA and extended into the CCA. However, coverage of the distal normal ICA was insufficient due to the tortuosity of the distal ICA. Final angiography revealed successful stent coverage of the distal normal ICA and entire lesion. The 3D-CT angiogram on the third postoperative day demonstrated stent migration into the CCA due to the shortening of the Carotid Wallstent and residual stenosis of the ICA. Therefore, a Precise stent was deployed using the PercuSurge GuardWire protection system to cover the ICA. Conclusions: In cases of CAS using the Carotid Wallstent, we should be alert to possible shortening and migration of the stent, especially if the lesion contains a tortuous ICA and the CCA diameter is large.
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Contralateral Cerebral Infarction after Stent Placement in Carotid Artery : An Unexpected Complication
Article
Full-text available
  • Oct 2008
Stenting is a useful alternative treatment modality in carotid artery stenosis patients who are too high-risk to undergo carotid endarterectomy (CEA). We report a case of contralateral cerebral infarction after stenting for extracranial carotid stenosis. A 78-year-old woman was admitted to the hospital with left-sided weakness. Based on magnetic resonance imaging (MRI) of the brain and conventional angiography, she was diagnosed with an acute watershed infarct of the right hemisphere secondary to severe carotid stenosis. Stenting was performed for treatment of the right carotid artery stenosis after a one-week cerebral angiogram was completed. Thirty minutes after stent placement, the patient exhibited a generalized seizure. Four hours later, brain MRI revealed left hemispheric cerebral infarction. Complex aorta-like arch elongation, tortuosity, calcification, and acute angulation at the origin of the supra-aortic arteries may increase the risk of procedural complications. In our case, we suggest that difficult carotid artery catheterization, with aggressive maneuvering during stenting, likely injured the tortuous, atherosclerotic aortic arch, and led to infarction of the contralateral cerebral hemisphere by thromboemboli formed on the wall of the atherosclerotic aorta.
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Shortening of Wallstent RP During Carotid Artery Stenting Requires Appropriate Stent Placement
Article
Full-text available
  • Jul 2008
  • NEUROL MED-CHIR
Changes in the location and length of the Wallstent RP during carotid artery stenting (CAS) were evaluated using intraoperative videos of 28 patients with carotid artery stenosis who underwent CAS with a 10/20 mm Wallstent RP to determine the appropriate stent placement. The stent was deployed after its midpoint was positioned over a virtual center line, the perpendicular line which crossed the most stenotic point of the lesion on the road mapping image. The length of the stenotic lesion, the changes in the locations of the distal and proximal ends of the stent, and the changes in stent length were examined. The distal end of the stent moved a maximum of 6.1 mm toward the proximal side to a point 19.9 mm from the virtual center line. The proximal end moved a maximum of 11.3 mm toward the distal side to a point 14.7 mm from the virtual center line. The stent length ranged from 37.7 to 44.5 mm (mean 41.2 mm). The 10/20 mm Wallstent RP placed by our technique covers the entire lesion with no less than 5.7 mm of margin over the segment distal to the lesion in patients with stenotic segments shorter than 29.4 mm.
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The role of carotid angioplasty and stenting in carotid revascularization
Article
  • Feb 2005
The gold standard procedure for carotid revascularization has been carotid endarterectomy. Several randomized trials demonstrate that it is more efficacious than medical management in stroke prevention for both symptomatic and asymptomatic patients when performed with low surgical morbidity. However, many high-risk patients not included in these trials are now being referred for carotid revascularization. Endovascular treatment of carotid stenosis with angioplasty and stenting has become an established alternative to carotid endarterectomy (CEA) for these patients. We provide a review of the current role of carotid stent and angioplasty. We reviewed our procedural techniques for carotid artery stenting (CAS) with an emphasis on the need for medical therapy before and after the procedure to reduce thromboembolic complications. We also retrospectively analysed our clinical outcomes and incidence of restenosis after CAS. We evaluated 139 of 252 patients treated over a 10-year period who had a minimum of 6-month clinical and imaging (ultrasound and/or angiography) follow-up (average f/u=60 months). Our rate of major stroke, MI or death was 3%, and rate of peri-operative TIAs was 2%. Morbidity related to femoral sheath placement has been 1.5%, with one 'cold foot' resolved with heparin and one retroperitoneal hematoma requiring transfusion. Recurrent stenosis after CAS occurred in 4% of patients, predominately following radiation treatment where it was 15%. Although CEA is the gold standard procedure to prevent stroke from carotid stenosis, CAS has an expanding role for revascualrization, particularly in high-risk patients. Several randomized prospective trials are ongoing to better define the indications for CAS versus CEA.
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Strategies for avoidance of nonembolic stroke during carotid artery stenting
Article
  • Mar 2007
Over the last decade many technical and pharmacological advances were made in order to improve the safety profile of carotid artery stenting (CAS). These advances largely addressed the issue of embolic stroke. It is clear, however, that despite each of these advances, which include dedicated carotid stents in place of adapted peripheral or coronary designs, low-profile rapid-exchange 0.014''-compatible equipment, cerebral protection devices and improvements in pharmacological support, there remains a finite risk of stroke and death associated with CAS. For example, the influence of one of these factors, the use of cerebral protection, employed in order to prevent embolic stroke, cannot be seen to be a panacea against procedural stroke. The 30-day results from the randomised trial SPACE, comparing CAS and carotid endarterectomy, indicated that the ipsilateral stroke and death rate was 7.3% in those patients in whom protection had been employed and 6.7% in unprotected patients. Clearly procedural stroke may result from other, nonembolic means such as haemodynamic disturbances and acute carotid occlusions. These factors must be recognised, considered, pre-empted and appropriately managed in order to further impact on the procedural event rate.
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Does Carotid Stent Cell Design Matter?
Article
  • Apr 2008
  • STROKE
Carotid stent cell design has recently been suggested to be a determinant of periprocedural and early postprocedural neurologic complications. We investigated the impact of closed- versus open-cell stent design on neurologic adverse events and mortality after carotid artery stenting. We studied 1684 consecutive patients (1010 asymptomatic, 674 symptomatic) from 10 European centers who underwent carotid artery stenting with either closed-cell (n=859, 51%) or open-cell (n=825, 49%) design stents. Rates of transient ischemic attack, stroke, and death on the day of the procedure (acute events) and from day 1 to day 30 after the procedure (subacute events) were analyzed (95% CIs). Combined transient ischemic attack, stroke, or death rates, and stroke or death rates within 30 days of treatment were 6.1% (95% CI, 5.0 to 7.2) and 3.1% (95% CI, 2.3 to 3.9) for the closed-cell design versus 4.1% (95% CI, 3.2 to 5.0) and 2.4% (95% CI, 1.7 to 3.1) for the open-cell design stents (P=0.077, P=0.38), respectively, without significant differences in asymptomatic and symptomatic patients. By propensity-score-adjusted multivariable analysis, the open-cell carotid stent design was not associated with a differential risk for combined acute and subacute neurologic complications compared with closed-cell stents (adjusted odds ratio=0.84, P=0.53). When analyzed separately, the risk for acute events on the day of the procedure (adjusted odds ratio=0.83, P=0.57) and the risk for subacute events at days 1 to 30 (adjusted odds ratio=1.61, P=0.51) also were not significantly different between the groups. Current data do not support the superiority of a specific carotid stent cell design with respect to neurologic complications, stroke, and mortality risk.
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Optimal Treatment of Carotid Artery Disease
Article
  • Apr 2008
Extracranial carotid artery disease accounts for approximately 25% of ischemic strokes. Although carotid endarterectomy (CEA) is the established gold standard for carotid revascularization, carotid artery angioplasty and stenting (CAS) is continually developing into a safer and more efficacious method of stroke prevention. Embolic protection, improving stent designs, and ever-increasing surgeon experience are propelling CAS towards equipoise with and possible superiority to CEA. One multicenter randomized trial and several nonrandomized registries have successfully established CAS as an accepted treatment for high-risk patients. Clinicians must strive to perform well-designed clinical trials that will continue to aid understanding and improve application of both endovascular and open techniques for extracranial carotid revascularization. We review the data published to date regarding the indications for and recent developments in the use of CAS.
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