Jorge H. Leguizamón

Midterm Results of a Sirolimus-Eluting Stent Implanted for Recurrent Carotid In-Stent Restenosis

One of the concerns about carotid artery stenting (CAS) is the development of restenosis. Although the incidence of restenosis is low (3% to 8% in large series) due to the large reference vessel diameter, the number of cases will continue to rise as more CAS procedures are performed each year. While drug-eluting stent implantation has replaced balloon angioplasty and brachytherapy for the treatment of in-stent restenosis in the coronary arteries, there is scarce information regarding their use for carotid in-stent restenosis. In 2007, Iancu and Lazar reported sustained patency of a drug-eluting stent 1 year after treatment for carotid in-stent restenosis. We have recently documented 30-month follow-up in a patient we treated for recurrent in-stent restenosis with a drugeluting stent. The 53-year-old diabetic woman with multiple comorbidities was seen for symptoms of bilateral carotid artery disease. Her left internal carotid artery (ICA) was chronically occluded, and the right ICA had an 80% stenosis (Figure, A); the intracranial circulation was free of hemodynamically significant lesions. An 8340-mm Wallstent under FilterWire EZ embolic protection (Boston Scientific, Natick, MA, USA) was implanted in the right ICA with excellent results (Figure, B). The patient was discharged on aspirin and clopidogrel, but 1 year later, she was seen for dizziness and left arm paresthesia. A high-grade in-stent restenosis was treated with balloon dilation without complications. Nine months later, the patient was admitted for unstable angina and left arm paresthesia. Ultrasound suggested a highgrade recurrent in-stent restenosis (Figure, C). Surgery was proposed but dismissed by the vascular surgeon due to the high cervical location of the stenosis and contralateral carotid occlusion, so we implanted a 3.5-333mm Cypher coronary stent (Cordis, Miami, FL, USA) under cerebral protection (Figure, D,E); the stent was further expanded with a 4.5-mm balloon. The patient was discharged on longterm aspirin and clopidogrel therapy. Thirty months later, she was admitted for left leg critical ischemia, but she was free of any neurological deficit or symptom. Carotid angiography showed no evidence of restenosis (Figure, F) in the right ICA stent.

Shock cardiogénico posinfarto: ¿tiene importancia clínica discriminar patrones hemodinámicos?

Resumen es: El shock cardiogenico continua siendo la principal causa de mortalidad en los pacientes hospi- talizados por un infarto agudo de miocardio a pesar de los...