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European Radiology

, Volume 29, Issue 1, pp 77–84 | Cite as

Detection of in-stent protrusion (ISP) by intravascular ultrasound during carotid stenting: Usefulness of stent-in-stent placement for ISP

  • T. OkazakiEmail author
  • S. Sakamoto
  • K. Shinagawa
  • N. Ichinose
  • D. Ishii
  • T. Matsushige
  • Y. Kiura
  • K. Kurisu
Interventional
  • 119 Downloads

Abstract

Objectives

As in-stent protrusion (ISP) during carotid artery stenting (CAS) may cause postoperative embolism, ISP detection is important. Intravascular ultrasound examination (IVUS) is useful for ISP detection because the blood vessel cross-section can be drawn as a tomogram from the lumen. Our objective was to clarify the occurrence of ISP during CAS using IVUS and relevant factors, and to report the usefulness of stent-in-stent placement when treating ISP.

Methods

In 142 consecutive patients (128 men, average age 71.7 years; 69 symptomatic) who underwent CAS using dual protection and the blood aspiration method, and subsequent IVUS after stent placement were included. The outcome of CAS, and the occurrence rate of ISP and related factors (plaque characteristics, stent design, intraoperative debris capture rate and postoperative diffusion-weighted imaging (DWI) positive rate) were examined.

Results

All CAS procedures were successful and no major adverse events (MAEs) were observed at 30 days. ISP was found in 12% (17/142), and stent-in-stent placement was performed in all cases. Vulnerable plaques were observed in 12 of 17 ISP cases (71%). A closed stent was used in 13 of 17 ISP cases (71%). The intraoperative debris capture rate was 100%, and no neurological symptoms were observed in any patients. A significant increase in ISP susceptibility was related to vulnerable plaques and the intraoperative debris capture rate.

Conclusions

Vulnerable plaques and debris capture were significantly correlated with ISP occurrence. In all ISP cases, stent-in-stent placement was performed and good results were obtained.

Key Points

• ISP detection during CAS using IVUS is important.

• ISP-positive patients were correlated with NASCET ≥ 80%, vulnerable plaques and stent length.

• Adequate additional treatment of stent in stenting under reliable protection against ISP-positive patients achieved low perioperative complications.

Keywords

Carotid stenosis Intravascular ultrasound Stents 

Abbreviations

AV

Arteriovenous

CAS

Carotid artery stenting

CC

Close-cell design stent

CCA

Common carotid artery

CEA

Carotid endarterectomy

CREST

Carotid Revascularization Endarterectomy vs. Stenting Trial

DSA

Digital subtraction angiography

DWI

Diffusion-weighted imaging

ECA

External carotid artery

HIS

High-intensity signal

ICA

Internal carotid artery

ISP

In-stent protrusion

IVUS

Intravascular ultrasound

MAE

Major adverse events

NASCET

North American Symptomatic Carotid Endarterectomy Trial

OC

Open-cell design stent

OCT

Optical coherence tomography

OFDI

Optical frequency domain imaging

PTA

Percutaneous transluminal angioplasty

TIA

Transient ischaemic attack

Notes

Funding

The authors state that this work has not received any funding.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Prof. Kaoru Kurisu.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• Retrospective

• Case-control study

• Performed at one institution

References

  1. 1.
    Uno M (2015) Carotid Endarterectomy. Jpn J Neurosurg (Tokyo) 24:840–845CrossRefGoogle Scholar
  2. 2.
    Shindo S, Fujii K, Shirakawa M et al (2016) Three-dimensional optical frequency domain imaging evaluation of novel dual-layered carotid stent implantation for vulnerable carotid plaque. J Stroke Cerebrovasc Dis 25:e31–e32CrossRefGoogle Scholar
  3. 3.
    Cremonesi A, Setacci C, Manetti R et al (2005) Carotid angioplasty and stenting: lesion related treatment strategies. EuroIntervention. 1:289–295PubMedGoogle Scholar
  4. 4.
    Bosiers M, de Donato G, Deloose K et al (2007) Dose free cell area influence the outcome in carotid artery stenting? Eur J Vasc Endovasc Surg. 33:135–141 [discussion: 142-143]CrossRefGoogle Scholar
  5. 5.
    Liu R, Jiang Y, Xiong Y et al (2015) An optical coherence tomography assessment of stent strut apposition based on the presence of lipid-rich plaque in the carotid artery. J Endovasc Ther. 22:942–949CrossRefGoogle Scholar
  6. 6.
    Sakamoto S, Kiura Y, Okazaki T et al (2015) Usefulness of dual protection combined with blood aspiration for distal embolic protection during carotid artery stenting. Acta Neurochir (Wien) 157:371–377CrossRefGoogle Scholar
  7. 7.
    Sakamoto S, Kiura Y, Okazaki T et al (2016) Carotid artery stenting for vulnerable plaques on MR angiography and ultrasonography: utility of dual protection and blood aspiration method. J Neurointerv Surg 8:1011–1015CrossRefGoogle Scholar
  8. 8.
    Hayashi K, Kitagawa N, Morikawa M et al (2009) A case of internal carotid artery stenosis complicated with shower embolism during filter-protected carotid artery stenting. Brain Nerve 61:83–87PubMedGoogle Scholar
  9. 9.
    Kuroiwa T, Sakai N, Adachi H et al (2004) Stent-in-stenting for the Plaque Protrusion after Stent Deployments. Surg Cereb Stroke 32:107–111CrossRefGoogle Scholar
  10. 10.
    Wehman JC, Holmes DR, Ecker RD et al (2006) Intravascular ultrasound identification of intraluminal embolic plaque material during carotid angioplasty with stenting. Catheter Cardiovasc Interv 68:853–857CrossRefGoogle Scholar
  11. 11.
    Kotsugi M, Takayama K, Myouchin K et al (2017) Carotid artery stenting. Investigation of plaque protrusion incidence and prognosis. JACC Cardiovasc Interv 10:824–831CrossRefGoogle Scholar
  12. 12.
    Shinozaki N, Ogata N, Ikari Y et al (2014) Plaque protrusion detected by intravascular ultrasound during carotid artery stenting. J Stroke Cerebrovasc Dis 23:2622–2625CrossRefGoogle Scholar
  13. 13.
    Aikawa H, Kodama T, Nii K et al (2008) Intraprocedural plaque protrusion resulting in cerebral embolism during carotid angioplasty with stenting. Radiat Med 26:318–323CrossRefGoogle Scholar
  14. 14.
    de Donato G, Setacci F, Sirignano P et al (2013) Optical coherence tomography after carotid stenting: rate of stent malapposition, plaque prolapse and fibrous cap rupture according to stent design. Eur J Vasc Endovasc Surg 45(6):579–587CrossRefGoogle Scholar
  15. 15.
    Yohimura S, Kawasaki M, Yamada K et al (2012) Visualization of internal carotid artery atherosclerotic plaques in symptomatic and asymptomatic patients: a comparison of optical coherence tomography and intravascular ultrasound. AJNR Am J Neuroradiol 33:308–313CrossRefGoogle Scholar
  16. 16.
    Yamada K, Yoshimura S, Miura M et al (2017) Potential of new-generation double-layer micromesh stent for carotid artery stenting in patients with unstable plaque: A preliminary result using OFDI analysis. World Neurosurg 105:321–326CrossRefGoogle Scholar
  17. 17.
    Yoshimura S, Yamada K, Kawasaki M et al (2011) High-intensity signal on time-of-flight magnetic resonance angiography indicates carotid plaques at high risk for cerebral embolism during stenting. Stroke 42:3132–3137CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Department of Neurosurgery, Graduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan

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