Angiographically occult in-stent protrusion detected by intravascular ultrasound during carotid artery stenting: a case report.

BACKGROUND

Carotid artery stenting (CAS) is an established revascularization strategy for carotid stenosis, but periprocedural ischemic events remain a concern. In-stent protrusion, representing plaque protrusion and/or adherent thrombus, may be clinically relevant and can be underestimated by angiography alone. Intravascular ultrasound (IVUS) provides cross-sectional visualization of the stent lumen and may detect lesions not apparent on digital subtraction angiography.

CASE PRESENTATION: We report the case of a 92-year-old man of Japanese ethnicity with symptomatic right internal carotid artery tandem stenoses treated with CAS under balloon protection. Completion angiography showed no intraluminal defect; however, IVUS demonstrated marked protrusion within the distal stent. Immediate rescue with an additional overlapping stent under re-occlusion eliminated the protrusion on repeat IVUS. The patient recovered without complications and was discharged home on postoperative day 4.

CONCLUSIONS

This case highlights that IVUS may detect angiographically occult in-stent protrusion and may help guide prompt intraprocedural rescue and confirmation of lumen optimization.