Hu Wei, Wang Li, Wang GuoPing
Department of Neurology, Affiliated Provincial Hospital of Anhui Medical University, Hefei, China.
Interv Neurol. 2018 Apr;7(5):265-270. doi: 10.1159/000486247. Epub 2018 Apr 3.
Based on the results of a recent randomized controlled trial, carotid artery stenting (CAS) was regarded as a relatively safe, less invasive treatment of internal carotid artery stenosis. However, cerebral thromboembolic events are the most common complications of CAS. Especially acute stent thrombosis following CAS will be fatal without prompt diagnosis and revascularization.
We report a case of acute stent thrombosis in whom carotid revascularization was performed successfully via arterial thrombolysis and balloon postdilation. A 79-year-old man with hypertension was hospitalized for an episode of transient ischemic attack. Computed tomography angiography revealed subtotal occlusion in the left carotid artery. Aspirin (100 mg) and clopidogrel (75 mg) were administered daily for 5 days before the procedure. CAS was performed under local anesthesia. The first postprocedural angiogram showed the stent looked good. However, a repeat angiogram showed in-stent thrombosis 2 min after withdrawal of the cerebral protection filter. Interestingly, the patient presented no neurologic deficit. After an additional 2,000 U of heparin had been administered intravenously, a microcatheter (SL-14; Boston Scientific, USA) was positioned to the in-stent thrombosis. Next, a total dose of 10 mg of recombinant tissue plasminogen activator was injected into the thrombus via the microcatheter within 10 min, which led to partial recanalization with antegrade flow. However, complete occlusion of the lesion occurred 5 min later. Under the guidance of angiography roadmap, a protection filter (Emboshield NAV6; Abbott Vascular, USA) was deployed at the distal part of the stent and redilation of the stent was performed with a 5 × 30 mm balloon (Viatrac 14 Plus; Abbott Vascular) at 14 atm. Finally, carotid revascularization was performed successfully, proven by postprocedural angiogram.
Acute carotid stent thrombosis (ACST) can have devastating effects on the survival of the patient. For ACST when the stent does not fully adhere to the blood vessel, a mechanical approach should be a feasible solution to the problem.
基于近期一项随机对照试验的结果，颈动脉支架置入术（CAS）被视为一种相对安全、侵入性较小的治疗颈内动脉狭窄的方法。然而，脑栓塞事件是CAS最常见的并发症。尤其是CAS后急性支架血栓形成，如果不及时诊断和再血管化将是致命的。
我们报告一例急性支架血栓形成患者，通过动脉溶栓和球囊后扩张成功实现颈动脉再血管化。一名79岁高血压男性因短暂性脑缺血发作入院。计算机断层血管造影显示左颈动脉次全闭塞。术前5天每天服用阿司匹林（100毫克）和氯吡格雷（75毫克）。CAS在局部麻醉下进行。术后首次血管造影显示支架情况良好。然而，取出脑保护滤网2分钟后重复血管造影显示支架内血栓形成。有趣的是，患者没有出现神经功能缺损。静脉追加2000单位肝素后，将一根微导管（SL - 14；美国波士顿科学公司）置于支架内血栓处。接下来，在10分钟内通过微导管向血栓内注射总量为10毫克的重组组织型纤溶酶原激活剂，导致部分再通并出现顺行血流。然而，5分钟后病变再次完全闭塞。在血管造影路线图引导下，在支架远端置入一个保护滤网（Emboshield NAV6；美国雅培血管公司），并用一个5×30毫米球囊（Viatrac 14 Plus；美国雅培血管公司）在14个大气压下对支架进行再扩张。最后，术后血管造影证实颈动脉再血管化成功。
急性颈动脉支架血栓形成（ACST）可对患者的生存产生毁灭性影响。对于支架未完全贴附血管的ACST，机械方法应是解决该问题的可行方案。
