Treatment of Carotid Artery In-Stent Restenosis Using a Drug Eluting Balloon Combined With the Transcarotid Artery Revascularization Flow Reversal System

Suwanee, GA

Introduction

In-stent restenosis (ISR) after carotid artery stenting presents a unique challenge to the vascular surgeon. While carotid endarterectomy remains the gold standard for symptomatic carotid stenosis, this option is often difficult in the setting of ISR, as stent extraction may require arterial reconstruction or interposition bypass. Drug-coated balloon (DCB) technology has demonstrated success in treating ISR in the lower extremities by reducing neointimal hyperplasia through paclitaxel-mediated inhibition of smooth muscle proliferation. Transcarotid artery revascularization (TCAR; Silk Road) has gained popularity due to its favorable safety profile, short learning curve, and reliable neuroprotection via flow reversal, as demonstrated in the ROADSTER II trial.

Objectives

The objective of this report is to describe the use of the TCAR neuroprotection platform to deliver drug-coated balloon therapy as an alternative treatment modality for carotid in-stent restenosis.

Methods

The patient underwent TCAR under general anesthesia with standard preparation, including open common carotid exposure and initiation of flow reversal via the contralateral femoral vein. A 4 mm × 30 mm plain balloon was used for pre-dilation, followed by a 7 mm × 40 mm drug-coated balloon (Lutonix, Medtronic) with a three-minute dwell time. Completion angiography demonstrated near-complete resolution of stenosis without complications.

Results

The patient was a 70-year-old male who presented following a transient ischemic attack with left-sided facial paresthesias, dysarthria, and left-hand weakness. His history was significant for prior transfemoral right carotid artery stenting over 10 years earlier, four-vessel coronary artery bypass grafting, hypertension, and hyperlipidemia. Imaging confirmed severe ISR. Due to the small caliber of the internal carotid artery and existing stent bulk, placement of an additional stent was avoided. At the six-week follow-up, the patient remained asymptomatic with normal duplex velocities and no evidence of recurrent ISR.

Conclusion

This case demonstrates that TCAR can safely and effectively be used to deliver drug-coated balloon therapy as an alternative treatment modality for carotid in-stent restenosis.