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  • Instent Restenosis After Carotid Stenting: Treatment Using an Off-Label Cardiac Scoring Balloon

    Final Number:

    Grant C. Sorkin MD; Travis Michael Dumont MD; Jorge Luis Eller MD; Maxim Mokin; Kenneth V. Snyder MD, PhD; Adnan Hussain Siddiqui MD, PhD; L. Nelson Hopkins MD; Elad I. Levy MD, FACS, FAHA, FAANS

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: The rate of instent restenosis after Carotid Artery Stenting (CAS) varies according to literature source and degree of restenosis, ranging from 1–21% over 12–18 months. Treatment of instent restenosis due to circumferential or calcified lesions can be difficult and refractory to angioplasty.

    Methods: We describe the first off-label use of a cardiac scoring balloon used in two patients for instent carotid restenosis refractory to angioplasty with conventional balloons. The AngioSculpt percutaneous transluminal coronary angioplasty (PTCA) scoring balloon catheters (AngioScore, Fremont CA, USA) are unique angioplasty balloons that have 3 rectangular scoring wires that spiral around the longitudinal axis of a semicompliant balloon. Compared to cutting balloons, AngioSculpt balloons are lower profile, more flexible given the spiral arrangement of scoring wires, and create more scoring marks per millimeter of plaque. This allows the ability to achieve higher nominal and burst pressures (as high as 20 atmospheres) suited for calcified and circumferential plaque.

    Results: Two patients with a history of carotid artery stenting 6 and 8 years ago, presented with symptomatic carotid instent restenosis caused by circumferential and calcified lesions, respectively (Figures 1,3,4). Angioplasty with conventional compliant and noncompliant balloons was unsuccessful. An AngioSculpt percutaneous transluminal coronary angioplasty (PTCA) scoring balloon catheter was successful in achieving vessel recanalization despite the refractory nature of these lesions (Figures 2,5). No further conventional balloons or use of cutting balloons were required.

    Conclusions: The AngioSculpt PTCA scoring balloon catheter can be a useful option for treatment of refractory calcified or circumferential carotid instent restenosis.

    Patient Care: We hope to demonstate another tool in the armamentarium in the treatment of complex carotid instent restenosis.

    Learning Objectives: By the conclusion of this session, participants should be familiar with the AngioSculpt PTCA scoring balloon catheter as option for the treatment of carotid instent restenosis.

    References: [1] Hobson RW, 2nd, Lal BK, Chakhtoura E, Goldstein J, Haser PB, Kubicka R, Cerveira J, Pappas PJ, Padberg FT, Jamil Z. Carotid artery stenting: analysis of data for 105 patients at high risk. J Vasc Surg. 2003;37:1234. [2] Kastrup A, Groschel K, Krapf H, Brehm BR, Dichgans J, Schulz JB. Early outcome of carotid angioplasty and stenting with and without cerebral protection devices: a systematic review of the literature. Stroke. 2003;34:813-9. [3] Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351:1493-501. [4] Cosottini M, Michelassi MC, Bencivelli W, Lazzarotti G, Picchietti S, Orlandi G, Parenti G, Puglioli M. In stent restenosis predictors after carotid artery stenting. Stroke Res Treat. 2010;2010. [5] Groschel K, Riecker A, Schulz JB, Ernemann U, Kastrup A. Systematic review of early recurrent stenosis after carotid angioplasty and stenting. Stroke. 2005;36:367-73. [6] Albiero R, Silber S, Di Mario C, Cernigliaro C, Battaglia S, Reimers B, Frasheri A, Klauss V, Auge JM, Rubartelli P, Morice MC, Cremonesi A, Schofer J, Bortone A, Colombo A. Cutting balloon versus conventional balloon angioplasty for the treatment of in-stent restenosis: results of the restenosis cutting balloon evaluation trial (RESCUT). J Am Coll Cardiol. 2004;43:943-9. [7] Bosiers M, Deloose K, Verbist J, Peeters P. Scoring and cutting balloons for SFA disease treatment. Endovascular Today. 2008:October 34-7. [8] Chakhtoura EY, Hobson RW, 2nd, Goldstein J, Simonian GT, Lal BK, Haser PB, Silva MB, Jr., Padberg FT, Jr., Pappas PJ, Jamil Z. In-stent restenosis after carotid angioplasty-stenting: incidence and management. J Vasc Surg. 2001;33:220-6. [9] Setacci C, de Donato G, Setacci F, Pieraccini M, Cappelli A, Trovato RA, Benevento D. In-stent restenosis after carotid angioplasty and stenting: a challenge for the vascular surgeon. Eur J Vasc Endovasc Surg. 2005;29:601-7. [10] Cotroneo AR, Pascali D, Iezzi R. Cutting balloon versus conventional balloon angioplasty in short femoropopliteal arterial stenoses. J Endovasc Ther. 2008;15:283-91. [11] Mauri L, Bonan R, Weiner BH, Legrand V, Bassand JP, Popma JJ, Niemyski P, Prpic R, Ho KK, Chauhan MS, Cutlip DE, Bertrand OF, Kuntz RE. Cutting balloon angioplasty for the prevention of restenosis: results of the Cutting Balloon Global Randomized Trial. Am J Cardiol. 2002;90:1079-83. [12] Scheinert D, Peeters P, Bosiers M, O'Sullivan G, Sultan S, Gershony G. Results of the multicenter first-in-man study of a novel scoring balloon catheter for the treatment of infra-popliteal peripheral arterial disease. Catheter Cardiovasc Interv. 2007;70:1034-9. Bendok BR, Hopkins LN. Cutting balloon angioplasty to treat carotid in-stent restenosis. J Invasive Cardiol. 2004;16:A16. [13] Bendok BR, Roubin GS, Katzen BT, Boulos AS, Levy EI, Limpijankit T, Qureshi AI, Guterman LR, Hopkins LN. Cutting balloon to treat carotid in-stent stenosis: technical note. J Invasive Cardiol. 2003;15:227-32. [14] AngioScore Inc.: AngioSculpt percutaneous transluminal coronary angioplasty (PTCA) scoring balloon catheter. Instruction for use. Accessed February 25, 2013. [15] AngioScore Inc. AngioSulpt Percutaneous Transluminal Scoring Balloon Catheter Accessed February 25, 2013 [16] Shah QA, Georgiadis AL, Suri MF, Rodriguez GJ, Qureshi AI. Cutting balloon angioplasty for carotid in-stent restenosis: case reports and review of the literature. J Neuroimaging. 2008;18:428-32.

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