Abstract
A 65-year-old female presented with severe left cervical internal carotid artery stenosis manifesting as repeated transient ischemic attacks(TIAs) consisting of right hemiparesis and motor aphasia. Carotid artery stenting (CAS) under distal protection was performed to prevent further ischemic events. This procedure was uneventful. However, the patient exhibited progressive right hemiparesis and motor aphasia three hours after CAS. Emergent angiography revealed carotid artery occlusion due to acute carotid in-stent thrombosis (ACIST). Mechanical thrombectomy was performed. The carotid artery was recanalized with small residual thrombus. The neurological deficits partial disappeared after mechanical thrombectomy following catheter directed thrombolysis combined with a continuous intra-arterial infusion of low-dose tirofiban for ACIST. Follow-up angiography 9 months after stenting showed lessens restenosis and no in-stent thrombosis. Carotid thrombosis after CAS can be resolved by mechanical thrombectomy combined with in-stent catheter directed intra-arterial thrombolysis with a continuous infusion of low-dose tirofiban for more than 24hr and subsequent treatment with antithrombotic agents. This management is a feasible solution to ACIST.
Highlights
Carotid artery stenting (CAS) shows potential as an effective and safe treatment to alleviate internal carotid artery (ICA) stenosis and prevent future ischemic stroke as well as the need for carotid endarterectomy (CEA) [1]
We describe a case of CAS complicated with stent thrombosis treated by mechanical thrombectomy following in-stent catheter directed thrombolysis
The neurological deficits partially improved immediately after mechanical thrombectomy. It needs to follow catheter directed thrombolytic combined with a continuous intra-arterial infusion of 150μg/hr tirofiban
Summary
Carotid artery stenting (CAS) shows potential as an effective and safe treatment to alleviate internal carotid artery (ICA) stenosis and prevent future ischemic stroke as well as the need for carotid endarterectomy (CEA) [1]. After withdrawing the stent delivery system and the cerebral protection filter, angiography performed immediately after CAS revealed sufficient dilation without thrombus (Fig.2CD). Three hours after CAS, the patient developed progressive right hemiparesis and motor aphasia again. Emergent angiography revealed stent occlusion due to acute carotid in-stent thrombosis (ACIST) (Fig.2E). The neurological deficits partially improved immediately after mechanical thrombectomy It needs to follow catheter directed thrombolytic combined with a continuous intra-arterial infusion of 150μg/hr (the low-dose is 0.1μg/kg/min and high-dose is 0.4μg/kg/min according to the instruction manual) tirofiban (Tirofiban Hydrochloride for Injection, Shandong new times Pharmaceutical Co., Ltd. China) for the ACIST (Fig.2J). The patient had not developed any new neurological deficits Her progress has been closely observed continuing two antiplatelet agents without further treatment
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