Hamann, Gerhard F.

Heiss, M. M.

Liebetrau, M.

Pfefferkorn, T.

English

Gerhard F. Hamann

Martin Liebetrau

Thomas Pfefferkorn

Markus M. Heiss

Crossref

Successful Systemic Thrombolysis for Carotid Stent Thrombosis

Universität München: Elektronischen Publikationen

Successful systemic thrombolysis for carotid stent thrombosis

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Short ReportsABCFax + 41 61 306 12 34E-Mail karger@karger.chwww.karger.com© 2002 S. Karger AG, BaselAccessible online at:www.karger.com/journals/eneEur Neurol 2002;48:37–39Successful Systemic Thrombolysis for CarotidStent ThrombosisGerhard F. Hamann a, Martin Liebetrau a, Thomas Pfefferkorn a,Markus M. Heiss baDepartment of Neurology andbDepartment of Surgery,Ludwig Maximilian University, Klinikum Grosshadern,Munich, GermanyCarotid artery stenting is an increasingly used treatment forcarotid artery stenosis [1–3]. The complications include minor andmajor stroke and peri-interventional death [4]. Stent thrombosis israrely reported to occur during the treatment of carotid stenosis, andthere has been one report on the successful use of a glycoprotein IIb/IIIa antagonist [5].Case ReportA 76-year-old man was admitted with symptoms consistent witha right middle cerebral artery (MCA) infarction. He was on his wayhome from a surgical ward, where he had received a stent 4 daysbefore. The stent had been placed in the right internal carotid artery(ICA) to treat a 70% ICA stenosis which produced right-sided amau-rosis fugax. The patient had had two previous endarterectomies onthe same side. Immediately after stenting, which was confirmed to besuccessful by angioscopy, the patient received aspirin and intrave-nous heparin. His postoperative course was uneventful. It wasplanned to maintain the patient on 300 mg aspirin daily, but on hos-pital discharge he had been given neither anticoagulation nor aspirinby mistake. The treatment regimen at that time did not include clopi-dogrel. The neurological examination showed hemiparesis, hemine-glect and hemianopia on the left side (NIHSS 16). The color-codedduplex sonography showed a thrombotic occlusion of the stentedright ICA (fig. 1a) and an occlusion of the right MCA. Cranial com-puted tomography only revealed on old, right-sided posterior wa-tershed infarct (fig. 2). The acute thrombosis of the stent was thoughtto be the source of an embolism of the right MCA. Since the patientfulfilled the criteria for intravenous thrombolysis, we started intrave-nous thrombolysis 2 h after the initial symptoms, using 70 mg rt-PA.Besides the thrombolysis, the patient immediately received intrave-nous heparin. The patient started to improve 30 min after initiationof thrombolysis. An ultrasound examination 1 h after the thromboly-sis revealed an open stent (see fig. 1b) and restored normal rightMCA blood flow velocity. The patient was discharged 5 days later.He still had a slight motor deficit (NIHSS 2), but a score of 1 on theRankin scale and a Barthel index of 100.DiscussionWhile stenting is widely used in cardiology, only limited experi-ence has been gathered on its use in carotid artery disease [1, 2].About 5,210 procedures have been reported worldwide (technicalsuccess rate 98.4%; transient ischemic attacks 2.82%, minor strokes2.72%, major strokes, 1.49%; deaths 0.86%) [1]. Various clinicaltrials are being planned or are in progress to establish the indicationsfor carotid artery stenting (CREST, SPACE, CASET) [6]. Recently,the Carotid and Vertebral Artery Transluminal Angioplasty Study(CAVATAS) demonstrated similar 3-year results for endovasculartreatment and carotid endarterectomy for major risks and effective-ness, and avoidance of minor complications [7]. Stent thrombosis is awell-known problem in cardiology [8]. A thrombosis rate of 3.5% wasreported as a first result [8]. Aggressive antiplatelet therapy, includ-ing the combined use of ticlopidin or clopidogrel and aspirin, reducesthe rate of stent thrombosis to approximately 1% [8]. Platelet activa-tion and aggregation may play a relevant role in the treatment ofthrombotic occlusion of stented vessel segments [9]. Abciximab hasbeen proposed in carotid stenting to prevent rethrombosis [9]. Thetreatment of early intracoronary stent thrombosis includes balloonangioplasty and intracoronary thrombolysis. Systemic thrombolysishas so far been attempted as a second therapeutic alternative [10].We performed an intravenous rt-PA thrombolysis similar to theknown NINDS protocol to reperfuse the MCA. In contrast to thisprotocol, heparin was given early because we hoped it would preventanother thrombosis, and indeed both the MCA and the thrombosedstent were recanalized. Thus, thrombolysis was able to dissolve alarge thrombus in the stent and an embolus in the MCA. After theintervention, we discovered a recent case report about the intrave-nous administration of a glycoprotein IIb/IIIa receptor antagonist torecanalize acute stent thrombosis [7]. To the best of our knowledge,this is the first report of the use of intravenous thrombolysis to suc-cessfully recanalize a carotid stent thrombosis with concomitantembolic MCA occlusion. Obviously, this single case can only help toilluminate the available treatment options rather than provide gener-al therapeutic recommendations.AcknowledgmentsGerhard F. Hamann is a recipient of a research grant from Böh-ringer Ingelheim Inc., Biberach an der Riss, Germany, in recognitionof his experimental work on the development of intracranial bleedingfollowing acute ischemic stroke.The authors want to express their warmest thanks to Mrs. J. Ben-son for editing the manuscript.38 Short ReportsFig. 1. a Color-coded duplex sonography of the right ICA demonstrating the thromboticocclusion of this vessel (arrow) before treatment. b Color-coded duplex sonography of theright ICA after systemic thrombolysis showing the restored blood flow and the reopenedvessel.Fig. 2. Cranial computed tomography 1 hafter the onset of initial symptoms of anacute MCA right-sided stroke. No early signsof infarction were detected, but an old wa-tershed infarction (arrow) is visible betweenthe territory of the MCA and the posteriorcerebral artery on the right side. Courtesy ofProf. Brückmann, Head Institute of Neuro-radiology, Ludwig Maximilian University,Munich, Germany.Short Reports 39References1 Wholey MH, Wholey M, Mathias K, Roubin GS, Diethrich EB, Henry M,Bailey S, Bergeron P, Dorros G, Eles G, Gaines P, Gomez CR, Gray B,Guimaraens J, Higashida R, Ho DS, Katzen B, Kambara A, Kumar V,Laborde JC, Leon M, Lim M, Londero H, Mesa J, Musacchio A, Myla S,Ramee S, Rodriguez A, Rosenfield K, Sakai N, Shawl F, Sievert H, Teitel-baum G, Theron JG, Vaclav P, Vozzi C, Yadav JS, Yoshimura SI: Globalexperience in cervical carotid artery stent placement. Cathet CardiovascInterv 2000;50:160–167.2 Roubin GS, New G, Iyer SS, Vitek JJ, Al-Mubarak N, Liu MW, Yadav J,Gomez C, Kuntz RE: Immediate and late clinical outcomes of carotidartery stenting in patients with symptomatic and asymptomatic carotidartery stenosis: A 5-year prospective analysis. Circulation 2001;103:532–537.3 Veith FJ, Amor M, Ohki T, Beebe HG, Bell PR, Bolia A, Bergeron P, Con-nors JJ 3rd, Diethrich EB, Ferguson RD, Henry M, Hobson RW 2nd, Hop-kins LN, Katzen BT, Matthias K, Roubin GS, Theron J, Wholey MH, Ya-dav SS: Current status of carotid bifurcation angioplasty and stenting basedon a consensus of opinion leaders. J Vasc Surg 2001;33:S111–S116.4 Mathur A, Roubin GS, Iyer SS, Piamsonboon C, Liu MW, Gomez CR,Yadav JS, Chastain HD, Fox LM, Dean LS, Vitek JJ: Predictors of strokecomplicating carotid artery stenting. Circulation 1998;97:1239–1245.5 Tong FC, Cloft HJ, Joseph GJ, Samuels OB, Dion JE: Abciximab rescue inacute carotid stent thrombosis. Am J Neuroradiol 2000;21:1750–1752.6 Hobson RW 2nd: Carotid angioplasty-stent: Clinical experience and rolefor clinical trials. J Vasc Surg 2001;33:S117–S123.7 CAVATAS Investigators: Endovascular versus surgical treatment in pa-tients with carotid stenosis in the Carotid and Vertebral Artery Translumi-nal Angioplasty Study (CAVATAS): A randomised trial. Lancet 2001;357:1729–1737.8 Baim DS, Carrozza JP Jr: Stent thrombosis. Closing in on the best pre-ventive treatment. Circulation 1997;95:1098–1100.9 Schneidermann J, Morag B, Gerniak A, Rimon U, Varon D, Seligsohn U,Shotan A, Adar R: Abciximab in carotid stenting for postsurgical carotidrestenosis: Intermediate results. J Endovasc Ther 2000;7:263–272.10 Fruhwald FM, Luha O, Eber B, Schuhmacher M, Zweiker R, Klein W:Systemic thrombolysis for early intracoronary stent thrombosis. Lancet1995;346:119–120.Prof. Gerhard F. Hamann, MD, Department of Neurology,Ludwig Maximilian University, Klinikum Grosshadern,Marchioninistrasse 15, D–81377 Munich (Germany)Tel. +49 89 7095 3670, Fax +49 89 7095 3677,E-Mail hamann@brain.nefo.med.uni-muenchen.de

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Global experience in cervical carotid artery stent placement. Cathet Cardiovasc Interv

Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: A 5-year prospective analysis.

JE: Abciximab rescue in acute carotid stent thrombosis.

Stent thrombosis. Closing in on the best preventive treatment. Circulation

Systemic thrombolysis for early intracoronary stent thrombosis. Lancet

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Successful systemic thrombolysis for carotid stent thrombosis

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