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A 54-year-old woman was admitted to our hospital with right hemiparesis. Her medical history was uncontrolled hypertension 5 years and minor ischemic stroke with right hemiparesis 1 month ago. Patient had no previous history of diabetes, cardiac pathologies, strokes, transient ischemic attacks, thromboembolic, or other vascular pathologies.
On examination, her blood pressure was 120/80 mmHg, heart rate was regular at 90 bpm, respiratory rate was 20 times/min, and blood sugar was 111.7 mg/dl. Her glomerular filtration rate was normal. Her pharmacological therapy once a day included as dual antiplatelet therapy (75 mg clopidogrel and 81 mg acetylsalicylic acid); rosuvastatin 20mg; bisoprolol 2.5mg; amlodipine 10 mg with valsartan 160 mg and pantoprazol 40 mg.
Magnetic Resonance Imaging (MRI) 3 Tesla brain revealed hyperintense lesions on the left hemisphere affected by ipsilateral internal carotid artery severe stenosis (Figure 1). This result was suitable for digital subtraction angiography (DSA). After 3 hours of procedure, we tried to angioplasty with balloon NeuroSpeed® PTA 2.0x8 (Acandis) and balloon Jade 3.5x80 mm (OrbusNeich), but stent could not approach to the stenosis site because of the tortuous type III aortic arch and left common carotid artery (Figure 2). The failure of carotid artery stenting made her symptoms from hemiparesis to hemiplegia and MRI demonstrated that more hyperintense lesions on the left hemisphere than the first MRI and left internal carotid artery near-occlusion (Figure 3).
Figure 1: First cerebral MRI: A) Hyperintense lesions on the left hemisphere (blue arrow); B) Ipsilateral internal carotid artery severe stenosis (green arrow).
Figure 2: First endovascular therapy: A) Tortuous type III aortic arch approached by 5F IMPRESS® Simmons 2 Catheter (Merit Medical) (blue arrow); B) Tortuous common carotid artery (red arrow); C) Perpendicular origin with internal carotid artery severe stenosis (yellow arrow); D) Angioplasty (green arrow); E) Restenosis internal carotid artery (white arrow).
Figure 3: Second cerebral MRI: A) More hyperintense lesions on the left hemisphere than the first MRI (blue arrow); B) Ipsilateral internal carotid artery near-occlusion (yellow arrow).
Figure 4: A) Exposure of common carotid artery (blue arrow); B) Sheath 8F introduced into common carotid artery (yellow arrow).
Figure 5: Second endovascular therapy: A) Internal carotid artery near-occlusion (blue arrow); B) Microwire advanced into petrous segment of internal carotid artery (red arrow); C) First angioplasty; D) Unsheathing the first stent (yellow arrow); E) Angiography after the first stent; F) Deployment of second stent (white arrow); G) Angioplasty after in-stent restenosis (green arrow); H, I) Left anterior circulation after carotid stenting in the lateral and anteroposterior planes, respectively.
Figure 6: Diagram of transcervical carotid flow reversal technique: A) Flow reversal from common carotid artery to the internal jugular vein [6]; B) Flow reversal from common carotid artery to the femoral vein [7].
One month later, we decided to change to the transcervical access to perform stenting. Patient was undergone under general anesthesia; the head was turned to the right and a small incision extended same as the length of thyroid gland (Figure 4).
After the exposure of left common carotid artery radifocus introducer sheath 8F (Terumo) was used then this artery was accessed by a co-axial system of catheter Ballast™ 088 Long Sheath (Balt) with diagnostic catheter Vertebral 5F (Merit Medical) and Wire 0.035” (Terumo), then making roadmap. Microwire Traxcess 0.014” (MicroVention) approached selectively into the petrous segment internal carotid artery, then balloon JADE 3.5x40 mm (OrbusNeich) was dilated stenosis site first. Next, stent BeSmooth Peripheral Stent System 6.0x58 mm (Bentley) and CGuardTM Embolic Prevention System 7.0x40 (InspireMD) were deployed respectively, but they were restenosis. Last angioplasty was realized with balloon Vecchio 5.0x18 (cNovate Medical). Finally, angiography recorded that recanalization was successful with TICI 3 (Figure 5). There was no complication relating to procedure after revascularization. She improved to good functional status with mRS 1 at 3 months after discharge.
On examination, her blood pressure was 120/80 mmHg, heart rate was regular at 90 bpm, respiratory rate was 20 times/min, and blood sugar was 111.7 mg/dl. Her glomerular filtration rate was normal. Her pharmacological therapy once a day included as dual antiplatelet therapy (75 mg clopidogrel and 81 mg acetylsalicylic acid); rosuvastatin 20mg; bisoprolol 2.5mg; amlodipine 10 mg with valsartan 160 mg and pantoprazol 40 mg.
Magnetic Resonance Imaging (MRI) 3 Tesla brain revealed hyperintense lesions on the left hemisphere affected by ipsilateral internal carotid artery severe stenosis (Figure 1). This result was suitable for digital subtraction angiography (DSA). After 3 hours of procedure, we tried to angioplasty with balloon NeuroSpeed® PTA 2.0x8 (Acandis) and balloon Jade 3.5x80 mm (OrbusNeich), but stent could not approach to the stenosis site because of the tortuous type III aortic arch and left common carotid artery (Figure 2). The failure of carotid artery stenting made her symptoms from hemiparesis to hemiplegia and MRI demonstrated that more hyperintense lesions on the left hemisphere than the first MRI and left internal carotid artery near-occlusion (Figure 3).
Figure 1: First cerebral MRI: A) Hyperintense lesions on the left hemisphere (blue arrow); B) Ipsilateral internal carotid artery severe stenosis (green arrow).
Figure 2: First endovascular therapy: A) Tortuous type III aortic arch approached by 5F IMPRESS® Simmons 2 Catheter (Merit Medical) (blue arrow); B) Tortuous common carotid artery (red arrow); C) Perpendicular origin with internal carotid artery severe stenosis (yellow arrow); D) Angioplasty (green arrow); E) Restenosis internal carotid artery (white arrow).
Figure 3: Second cerebral MRI: A) More hyperintense lesions on the left hemisphere than the first MRI (blue arrow); B) Ipsilateral internal carotid artery near-occlusion (yellow arrow).
Figure 4: A) Exposure of common carotid artery (blue arrow); B) Sheath 8F introduced into common carotid artery (yellow arrow).
Figure 5: Second endovascular therapy: A) Internal carotid artery near-occlusion (blue arrow); B) Microwire advanced into petrous segment of internal carotid artery (red arrow); C) First angioplasty; D) Unsheathing the first stent (yellow arrow); E) Angiography after the first stent; F) Deployment of second stent (white arrow); G) Angioplasty after in-stent restenosis (green arrow); H, I) Left anterior circulation after carotid stenting in the lateral and anteroposterior planes, respectively.
One month later, we decided to change to the transcervical access to perform stenting. Patient was undergone under general anesthesia; the head was turned to the right and a small incision extended same as the length of thyroid gland (Figure 4).
After the exposure of left common carotid artery radifocus introducer sheath 8F (Terumo) was used then this artery was accessed by a co-axial system of catheter Ballast™ 088 Long Sheath (Balt) with diagnostic catheter Vertebral 5F (Merit Medical) and Wire 0.035” (Terumo), then making roadmap. Microwire Traxcess 0.014” (MicroVention) approached selectively into the petrous segment internal carotid artery, then balloon JADE 3.5x40 mm (OrbusNeich) was dilated stenosis site first. Next, stent BeSmooth Peripheral Stent System 6.0x58 mm (Bentley) and CGuardTM Embolic Prevention System 7.0x40 (InspireMD) were deployed respectively, but they were restenosis. Last angioplasty was realized with balloon Vecchio 5.0x18 (cNovate Medical). Finally, angiography recorded that recanalization was successful with TICI 3 (Figure 5). There was no complication relating to procedure after revascularization. She improved to good functional status with mRS 1 at 3 months after discharge.