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Radiology
CAROTID
ANGIOPLASTY AND STENTING
A 68-year-old male patient, a known hypertensive and suffering from coronary artery disease, presented with three episodes of right sided transient ischaemic attacks
in the last year, the most recent one being three months ago. The patient was on anti-platelet treatment.
On clinical examination, there was a bruit over the left side of the neck. Colour Doppler study of cervical carotid vessels showed >80% stenosis of left internal carotid
artery origin. MRA of neck vessels revealed stenosis of both internal carotid arteries. Diagnostic four vessel angiogram was performed which showed a >90% stenosis
at the origin of left internal carotid artery and 60% stenosis at the origin of right internal carotid artery. Angiography of the intracranial circulation was unremarkable. A diagnosis of carotid artery disease was made and endovascular treatment was planned. We planned to stent the severely stenotic origin of left internal carotid artery,
which was symptomatic.
Procedure:
Under local anaesthesia, percutaneous access was obtained with Seldinger technique through the right femoral artery.
An 8 Fr. guiding catheter was placed in the proximal left common carotid artery. An EPI Filter Wire (Boston Scientific Corporation) was placed in the left cervical
internal carotid artery distal to stenosis. Once the filter was positioned and opened direct stenting was undertaken. A monorail, 8x30 mm. self expandable Carotid
Wall stent (Boston Scientific Corporation) was placed across the lesion and was deployed. The stent was post dilated using 6x20 mm. Gazelle monorail balloon
(Medi Tech, Boston Scientific Corporation). The final angiogram showed optimal result with excellent dilation of stenotic segment. Small amounts of plaque debris was recovered from the retrieved filter. The patient did not develop any ischaemic symptoms in the periprocedural period. He will continue to be on anti platelet drugs. Follow
up with Colour Doppler is planned after three months
Discussion :
Although endartrectomy is considered to be the gold standard treatment for carotid artery stenosis, it is not free of complications. In the NASCET (North American symptomatic carotid endartrectomy trial) study population, 5.8% of patients suffered from perioperative stroke and death, and it was also reported that subgroups of patients at high risk had mortality and morbidity rates of up to 18%. Since the first percutaneous transluminal carotid angioplasty (PTA) was performed by Kerber in
1980, rapid improvements in interventional technology and materials have contributed to the increasing popularity of this technique.
Percutaneous Transluminal Angioplasty with Carotid Stenting (PTACS) has led to the achievement of optimal immediate angiographic results and has become a
standard percutaneous approach to carotid artery stenosis. Acceptable rates of immediate complications (particularly in patients at high surgical risk) have been
reported in several studies, with good long term results after carotid stenting. In addition, the recent introduction of distal protection devices like the EPI filter wire used
in our procedure has lowered the rate of periprocedural acute cerebral ischaemic complications, thus enhancing the safety of the percutaneous approach, which can
thus be performed with good results even in high risk patients.
Case 15 : Contributed
by Dr. Chalapati Rao
Other Cases
A 68-year-old male patient, a known hypertensive and suffering from coronary artery disease, presented with three episodes of right sided transient ischaemic attacks
in the last year, the most recent one being three months ago. The patient was on anti-platelet treatment.
On clinical examination, there was a bruit over the left side of the neck. Colour Doppler study of cervical carotid vessels showed >80% stenosis of left internal carotid
artery origin. MRA of neck vessels revealed stenosis of both internal carotid arteries. Diagnostic four vessel angiogram was performed which showed a >90% stenosis
at the origin of left internal carotid artery and 60% stenosis at the origin of right internal carotid artery. Angiography of the intracranial circulation was unremarkable. A diagnosis of carotid artery disease was made and endovascular treatment was planned. We planned to stent the severely stenotic origin of left internal carotid artery,
which was symptomatic.
Procedure:
Under local anaesthesia, percutaneous access was obtained with Seldinger technique through the right femoral artery.
An 8 Fr. guiding catheter was placed in the proximal left common carotid artery. An EPI Filter Wire (Boston Scientific Corporation) was placed in the left cervical
internal carotid artery distal to stenosis. Once the filter was positioned and opened direct stenting was undertaken. A monorail, 8x30 mm. self expandable Carotid
Wall stent (Boston Scientific Corporation) was placed across the lesion and was deployed. The stent was post dilated using 6x20 mm. Gazelle monorail balloon
(Medi Tech, Boston Scientific Corporation). The final angiogram showed optimal result with excellent dilation of stenotic segment. Small amounts of plaque debris was recovered from the retrieved filter. The patient did not develop any ischaemic symptoms in the periprocedural period. He will continue to be on anti platelet drugs. Follow
up with Colour Doppler is planned after three months
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Fig.
1. Left common carotid angiogram AP & Lat. views showing tight stenosis
of internal carotid artery origin.
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Fig.
2. Protection device (EPI Filter Wire) was placed in distal cervical
internal carotid artery.
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Fig.
3. Wall Stent was deployed across the stenosis
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Fig.
4. Stent was post dilated with Gazelle monorail balloon
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Fig.
5 Post procedure angiogram showing optimal dilatation
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Although endartrectomy is considered to be the gold standard treatment for carotid artery stenosis, it is not free of complications. In the NASCET (North American symptomatic carotid endartrectomy trial) study population, 5.8% of patients suffered from perioperative stroke and death, and it was also reported that subgroups of patients at high risk had mortality and morbidity rates of up to 18%. Since the first percutaneous transluminal carotid angioplasty (PTA) was performed by Kerber in
1980, rapid improvements in interventional technology and materials have contributed to the increasing popularity of this technique.
Percutaneous Transluminal Angioplasty with Carotid Stenting (PTACS) has led to the achievement of optimal immediate angiographic results and has become a
standard percutaneous approach to carotid artery stenosis. Acceptable rates of immediate complications (particularly in patients at high surgical risk) have been
reported in several studies, with good long term results after carotid stenting. In addition, the recent introduction of distal protection devices like the EPI filter wire used
in our procedure has lowered the rate of periprocedural acute cerebral ischaemic complications, thus enhancing the safety of the percutaneous approach, which can
thus be performed with good results even in high risk patients.