Instent restenosis after carotid stenting: treatment using an off-label cardiac scoring balloon

Carotid artery stenting (CAS) has emerged as an important alternative to endarterectomy for the management of carotid stenosis [1–3]. Rates of instent restenosis after CAS vary according to literature source and definition of restenosis, ranging from 1% to 21% over 12–18 months, with its treatment dependent on vascular and plaque morphology [4,5]. Treatment of instent restenosis with conventional angioplasty balloons (compliant or noncompliant) caused by circumferential or calcified lesions can be difficult because of inadequate luminal expansion, high dissection rate, and need for repeated revascularization procedures [6–9]. To overcome these obstacles, cutting and scoring balloons have been used in multiple vascular beds in primary stenting for highgrade or concentrically calcified stenosis and for instent restenosis that is refractory to angioplasty with conventional angioplasty balloons