Balloon Angioplasty for In-Stent Restenosis Resulting in Carotid Stent Fracture: Literature Review of Stent-in-Stent Technique as a Viable Therapeutic Option.

BACKGROUND: Carotid stent fractures are rare, and multiple etiologies have been proposed to explain their occurrence. We describe a patient with an internal carotid artery (ICA) stent who developed in-stent restenosis. We performed balloon angioplasty to address in-stent restenosis, but he developed a carotid stent fracture after the procedure. To our knowledge, balloon angioplasty has not been reported to cause stent fractures.

CASE DESCRIPTION: A 72-year-old man underwent stent placement for symptomatic left ICA stenosis with residual stenosis of 55% after stent placement. He presented with transient ischemic attacks 2 months later, and work-up revealed in-stent restenosis of the left ICA. Given prior complete occlusion of right ICA and right vertebral artery and narrowing of left vertebral artery ostium, satisfactory balloon (5 × 40 mm) angioplasty was carried out. After balloon angioplasty, x-ray showed a new stent fracture, which was initially missed on immediate postoperative imaging. He presented 9 months later with symptoms of compromised cerebral perfusion. Work-up revealed the previously missed stent fracture causing blood flow changes. Peak systolic velocity in the left ICA was 383 cm/second. He underwent left ICA repeat stent placement via a stent-in-stent technique for symptomatic severe left ICA stenosis of 70% with 40% residual stenosis after new stent deployment.

CONCLUSIONS: Balloon angioplasty to address in-stent restenosis can secondarily cause stent fractures. We provide evidence of successful management of stent fracture with recurrent in-stent stenosis by repeat stent placement via a stent-in-stent technique.