In-Stent Ulceration: An Unusual Pathology

In-stent restenosis occurs in 10–60% of cases undergoing interventional therapy. Many mechanisms explain the reason for in-stent restenosis, but restenosis due to an ulcerated plaque is very rare and has not been well reported in the literature. We report an interesting case of 72-year-old man presenting with neurological symptoms secondary to in-stent restenosis of the carotid artery caused by an ulcerated plaque. We also explain the different mechanisms for restenosis along with the treatment options. 1. Introduction Interventional therapy has been highly impacted by the number of lesions treated with stents, which exceeds 50% of all interventional procedures. Although stents have been successful in reducing the restenosis compared to balloon angioplasty, in-stent restenosis (ISR) occurs in 10–60% of cases [1–4]. ISR can be explained by many mechanisms, but restenosis due to an ulcerated plaque is very rare and has not been reported in the literature. We report a case where a patient presented with neurological symptoms secondary to an ulcerated ISR of the carotid artery. 2. Case Report A 72-year-old Caucasian man with past medical history of diabetes mellitus, hypertension, smoking, bilateral carotid endarterectomy, and a left carotid artery stent (14 months ago) presented with symptoms of blurred vision and dizziness. He experienced very similar symptoms prior to the past carotid endarterectomy. A subsequent carotid ultrasound showed a 60–79% stenosis of his left internal carotid artery and no significant stenosis of the right internal carotid artery. Carotid angiography showed an eccentric stenosis in the left internal carotid artery at the stent site with a crater/ulcer within the restenosis tissue inside the stent (Figure 1(a)). An Accunet 6.5 filter (Abbott Vascular, Santa Clara, CA) was deployed distal to the stent in the left internal carotid artery. Later, an Acculink (Abbott Vascular) ？mm self-expanding stent was deployed successfully. Postdeployment angiograms revealed brisk flow with no evidence of embolization into the filter, but the ulcerative nature of the crater continued to be present. Balloon dilatation was performed in the mid-portion of the stent after which residual stenosis was approximately 10% with minimal visualization of the crater-like lesion (Figure 1(b)). After successfully retrieving the filter device, final angiograms of cervical and cerebral arteries revealed brisk flow with no evidence of distal embolization maintaining patency of the middle cerebral and anterior cerebral circulation. At the 3-, 6-, 12-, and 24-month