Carotid Artery In-Stent Restenosis Resolved with Drug-Eluting Stenting

We were pleased to have our Clinical Decision Making article “Carotid Artery In-Stent Restenosis in a Patient with Contralateral Total Occlusion, Resolved with Drug-Eluting Stenting” published in the June 2007 issue of the Journal of Invasive Cardiology (2007;19:275–279). We are particularly compelled to respond to Dr. Nanjundappa’s commentary on our case. We had considered, as Dr. Nanjundappa did, that restenosis in this case was not a benign process. It was clear that this was a true restenosis, as reflected by the velocities on Doppler examination (systolic velocity of 400 cm/sec, diastolic velocity of 120 cm/sec), and we proceeded in consequence. Keeping in mind the study by Abou-Chebl et al “Drug- Eluting Stents for the Treatment of Intracranial Atherosclerosis: Initial Experience and Midterm Angiographic Follow-Up” published in Stroke (2005;36:168–265), we considered implantation of a drugeluting stent to be a good option. Their study demonstrated good results with drug-eluting stents in carotid arteries and no toxic effects. In fact, this is supported by Gupta and colleagues’ study published recently in Stroke (2006;37;2562–2566) “Safety, Feasibility, and Short-Term Follow-Up of Drug-Eluting Stent Placement in the Intracranial and Extracranial Circulation”.

We were not preoccupied by the possible deformation of the stent because its position was high in the internal carotid artery and mechanical protection was provided by the previous self-expanding stent.

Dr. Nanjundappa’s remark about using an undersized balloon was very pertinent, but in this case of major emergency, it was the only option we had (we expanded the balloon to 18 atm to achieve the maximum diameter). Finally, we can extrapolate that the drug-eluting stent thrombosis into the left main coronary artery produced the same catastrophic consequences as in the carotid arteries (in our case, the right carotid artery); this, however, did not diminish our enthusiasm for placing drug-eluting stents in the left main artery.