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BRIEF COMMUNICATIONS: Jan-Hendrik Buhk, Andreas Wellmer, and Michael Knauth Late in-stent thrombosis following carotid angioplasty and stenting Neurology 2006; 66: 1594-1596 [Abstract] [Full text] [PDF]

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Late in-stent thrombosis following carotid angioplasty and stenting

Raffi Topakian, MD, Karin Nussbaumer, MD; Johannes Trenkler, MD; Franz T. Aichner, MD   (14 July 2006)

Reply from the Authors

Jan-Hendrik Buhk, Andreas Wellmer, and Michael Knauth   (14 July 2006)

Late in-stent thrombosis following carotid angioplasty and stenting 14 July 2006
Raffi Topakian, MD, Department of Neurology Wagner-Jauregg-Hospital, 4020 Linz, Austria, Europe, Karin Nussbaumer, MD; Johannes Trenkler, MD; Franz T. Aichner, MD Send Correspondence to journal: Re: Late in-stent thrombosis following carotid angioplasty and stenting raffi.topakian{at}hotmail.com Raffi Topakian, MD, et al.	Bukh et al described three cases out of 96 carotid artery stenting (CAS) procedures with late in-stent thrombosis. [1] We want to stress the importance of a long-term antiplatelet regimen and control of medication compliance after CAS with an additional case report. In a cohort of more than 180 CAS procedures in our hospital, we observed one patient with late symptomatic in-stent thrombosis. The 76-year-old man underwent CAS for >90% asymptomatic stenosis of the right internal carotid artery (ICA). At routine follow-up 3 months after CAS, neurological evaluation and duplex ultrasound of the right ICA were unremarkable. The patient admitted discontinuation of the antiplatelet medication (75 mg clopidogrel and 100 mg aspirin) soon after CAS because of new-onset pruritus and gastrointestinal discomfort. Therefore, he was placed on the combination of dypiridamole and aspirin (200mg and 25mg, twice daily). Although he did not experience new side effects, he also discontinued the new antiplatelet regimen after 14 days without reporting it to his physicians. Fifteen months after the CAS procedure, he presented to our Neurological Department with subacute left-sided hemiparesis. MRI showed ischemic infarctions in the territory of the right middle cerebral artery and the posterior borderzone. Magnetic resonance angiography and duplex ultrasound revealed complete thrombotic occlusion of the stented right ICA. This case illustrates that long-term platelet inhibition is obligatory to reduce the probability of delayed stent thrombosis. Stent thrombosis may develop on the basis of in-stent restenosis which is a consequence of prolonged inflammatory processes in the stented vessel wall with excessive myointimal proliferation. [2] It is still unclear whether, apart from platelet inhibitors, statins and other medication with anti-inflammatory and anti-platelet-aggregability effects may help reduce the incidence of restenosis and in-stent thrombosis after CAS. Continuing control of medication compliance seems to be of paramount importance after CAS. References 1. Buhk JH, Wellmer A, Knauth M. Late in-stent thrombosis following carotid angioplasty and stenting. Neurology 2006;66:1594-1596. 2. Shah PK. Inflammation, neointimal hyperplasia, and restenosis. Circulation 2003;107:2175-2177. Disclosure: The authors report no conflicts of interest.
Reply from the Authors 14 July 2006
Jan-Hendrik Buhk, Dept. of Neuroradiology, University of Goettingen Robert-Koch-Str. 40, D-37075 Goettingen, Germany, Andreas Wellmer, and Michael Knauth Send Correspondence to journal: Re: Reply from the Authors jh.buhk{at}med.uni-goettingen.de Jan-Hendrik Buhk, et al.	Topakian et al describe an additional case of a delayed and symptomatic stent thrombosis following carotid angioplasty and stenting (CAS) similar to the cases we presented. [1] Although it is still unclear whether the stent occlusion in their case was secondary thrombosis due to in-stent restenosis or instable restenosis on the basis of an organized stent thrombosis, they point out relevant conclusions that might lead to consequences in the follow-up management of patients treated with CAS. Periinterventional anti-platelet and anticoagulation regimen is standardized and can be controlled by the interventionalist. However, anti-platelet follow-up is also important but depends on unpredictable factors including patient compliance. We propose a controlled patient follow-up to be provided by the center performing the procedure. In addition, drugs are being tested on their benefit in follow-up treatment after stent implantation, e.g. statins or cilostazol, but curren experimental or study data mainly address coronary stenting [3,4] and are not completely transferable to CAS. Furthermore, the duration of a postinterventional anti-platelet medication following CAS has not been determined and differs from center to center. Topakian et al point out the importance of inflammation processes that lead to stent thrombosis and restenosis. In the future, an optimized individualized treatment for every patient could be achieved in controlling both inflammatory response and platelet function before treatment as well as during follow-up. [3,5] References 3. Holmes DR Jr. Antiplatelet therapy after percutaneous coronary intervention. Cerebrovasc Dis 2006;21 Suppl 1:25-34. 4. Lee SW, Park SW, Hong MK, et al. Triple versus dual antiplatelet therapy after coronary stenting: impact on stent thrombosis. J Am Coll Cardiol 2005;46:1833-1837. 5. Gaspardone A, Versaci F. Coronary stenting and inflammation. Am J Cardiol 2005;96(12A):65L-70L. Disclosure: The authors report no conflicts of interest.