title: Balloon Angioplasty for In-Stent Restenosis Resulting in Carotid Stent Fracture: Literature Review of Stent-in-Stent Technique as a Viable Therapeutic Option.
abstract: BACKGROUND
  Carotid stent fractures are rare, and multiple etiologies have been proposed to explain their occurrence. We describe a patient with an internal carotid artery (ICA) stent who developed in-stent restenosis. We performed balloon angioplasty to address in-stent restenosis, but he developed a carotid stent fracture after the procedure. To our knowledge, balloon angioplasty has not been reported to cause stent fractures.
  
  
  METHODS
  A 72-year-old man underwent stent placement for symptomatic left ICA stenosis with residual stenosis of 55% after stent placement. He presented with transient ischemic attacks 2 months later, and work-up revealed in-stent restenosis of the left ICA. Given prior complete occlusion of right ICA and right vertebral artery and narrowing of left vertebral artery ostium, satisfactory balloon (5 × 40 mm) angioplasty was carried out. After balloon angioplasty, x-ray showed a new stent fracture, which was initially missed on immediate postoperative imaging. He presented 9 months later with symptoms of compromised cerebral perfusion. Work-up revealed the previously missed stent fracture causing blood flow changes. Peak systolic velocity in the left ICA was 383 cm/second. He underwent left ICA repeat stent placement via a stent-in-stent technique for symptomatic severe left ICA stenosis of 70% with 40% residual stenosis after new stent deployment.
  
  
  CONCLUSIONS
  Balloon angioplasty to address in-stent restenosis can secondarily cause stent fractures. We provide evidence of successful management of stent fracture with recurrent in-stent stenosis by repeat stent placement via a stent-in-stent technique.
authors.affiliation: Division of Neurosurgery, Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada. Electronic address: abdul.naeem@lhsc.on.ca.
authors.forename: Abdul-Haseeb
authors.initials: AH
authors.lastname: Naeem
authors.affiliation: Division of Neurosurgery, Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada.
authors.forename: Ghaya
authors.initials: G
authors.lastname: Al-Rumaihi
authors.affiliation: Department of Medical Science, Western University, London, Ontario, Canada.
authors.forename: Amirpouyan
authors.initials: A
authors.lastname: Namavarian
authors.affiliation: Department of Medical Imaging, London Health Sciences Centre, London, Ontario, Canada.
authors.forename: Manas
authors.initials: M
authors.lastname: Sharma
authors.affiliation: Division of Neurosurgery, Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada.
authors.forename: Melfort
authors.initials: M
authors.lastname: Boulton
mesh_terms: D000368:Aged; D000800:Angioplasty, Balloon / Q000379:methods*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging*; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging* / Q000209:etiology; D006801:Humans; D008297:Male; D011475:Prosthesis Failure / Q000009:adverse effects*; D015607:Stents / Q000009:adverse effects*
keywords: Carotid stenosis; Carotid stent; Recurrent stent stenosis; Stent-in-stent technique