We had reported the case of a 57-year-old male patient with a history of acute amaurosis fugax. Carotid angiography was performed as blood pressure differed between his left and right arms and there was a pan-systolic murmur on the left common carotid artery. Total occlusion of the proximal right brachiocephalic artery and a thrombus occluding 90–99% of the left internal carotid artery were detected by carotid angiogram. We decided to place a graft-covered stent through the lesion first, and contain the plaque and thrombus between the stent and the lumen. Therefore, a graft covered stent (5×13, Direct) was implanted with 12 atm pressure. After removing the distal blockingbased protection system, we opened the selfexpanding stent (7×10×30, Cristallo) (figure 3) and dilated the stent using a post-dilatation balloon5×20, Tarcomgrande).
A self-expanding graft-covered stent was successfully implanted and there were no complications. This case published in BMJ Case Journal “ Covered stents may provide extra protection during carotid artery stenting in high risk patients with an excessive thrombus burden”, Tatli E, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010258.
However , the patient presented transient ischemic attacks after three years. DSA angiography show 99% instent restenosis in the overleap segment of the both stent.
What are your opinion with this case ?
In our department with surgical treatment of more than 300 patients per year this patient would be treated with open vascular surgery under general anesthesia, using a temporary intraluminal shunt intraoperatively, extraction of all stents and stentgrafts, and replacement of the internal carotid by vein graft (greater saphenous vein).
Well, normally we would assess the degree of stenosis and the inner surface of the vessel by ultrasound. This does not work accurately with all the material already implanted. My decision would be strongly influenced by the patients´symptoms. Unless the patient has proof of intracardiac thrombus or other pathologies leading to bilateral embolism and bilateral neurologic symptoms, I would operate.
Dear Ersan Tatli,
I agree with Tina U Cohnert:
Open vascular surgery under general anesthesia, using a temporary intraluminal shunt and vein patch.
I am sorry that I can't answer it cause I am not a Medical Doctor. I am studying on Plastic Composites.
The patient was relatively young when the decision of stenting was made.The brachiocepahlic artery was occluded. The left carotid severely stenotic. Despite hese severe angiografic findings his only symptoms were those concerning the amaurosis ( I presume on his left eye): No further clinical informations are available. Cardiological Status? Carcinoma or other diseases? I wonder who took, with these angiografic findings, the decision of stenting . If his general conditions were extremely poor I may understand the decision but he is still living three years after stenting, in this case the stenting was not a decision for the patient but for the interventionalist . I can't believe that an experienced surgical team would have agreed to stent the "patient". Carotid surgery should have been first choice ( no clinical informations available). Now? You need a good surgeon, an even better anesthesist and a good intensive care unit. In the future? More humility. Best regards
Dear Ersan Tatli! I've looked through your publication and didn't find any data on patency of left vertebral artery. Did you perform selective left subclavian artery catheterization? Also, I'm of sure, that this patient has right vertebral-subclavian steal-syndrome. Firstly, I suggest to recanalize innominate artery occlusion via right brachial access with subsequent stenting. After blood flow restoration in right CCA, ICA and VA you could make decision on left ICA in-stent restenosis: treat it with one more angioplasty with stenting or perform open vascular reconstruction with CCA-ICA graft replacement (I suppose this patient would tolerate left carotid clamping better after innominate artery reconstruction). Our opinion - not to use vena saphena, because we observed it's aneurysmal degeneration in patient with CCA-subclavian bypass. We prefer knitted or PTFE grafts.
Dear Petr Galkin ,the patient of the left vertebral artery patent. I agree with your opinion. I think that this patient has right vertebral-subclavian steal-syndrome. I suggest to recanalize innominate artery total occlusion on first step.
Thank you for your attention
Dear Dr Tatli. The patient has a symptomatic Lt ICA >90%. Please operate on him performing carotid endarterectomy after stent excision, while measuring the stump pressure and using a temporal shunt. After you have fixed the symptomatic carotid you could see the problem in the innominate, which I'm not sure if it has a clear indication to be fixed after all. At last the present covered stents may not be a good solution for carotid artery because of the huge intimal hyperplasia they usually caused. At this case you would have better results if you used a more rigid close cell stent as for example x-act. Cristallo does not have enough strength to keep open such a stenosis along with the covered stent.
Dear Dr. Tatli, if you have experience in open carotid surgery you need first estabilice the sintomatic carotid, for this the best is performing a carotid endarterectomy with temporary shunt and angioplasty with PTFE pacht. It is not a easy operation. After this first steep your patient could bee asyntomatic, if not and if you are sure the patient have a right vertebral subclavian steal síndrome you have two diferents posiblities: a carotid-carotid bypass or an endovascular solution for the recth carotid oclusión.
It could be that the restenosis is an area where there was incomplete coverage, unrecognized angulation in post procedure neck posture, or an unrecognized shelf at the prior procedure. It could be a simple fix with bare or PTFE covered stent now. As long as you're not carrying the stent to an even higher endpoint, we would do that now, follow with ultrasound every six months, and do an open definitive procedure with gsv if there is another restenosis.
I think that in the first operation an Hybrid procedure was advised : open surgey to remove the thrombus in the internal carotid artery and retrograde stenting of brachiocefalic trunk. In in stent restenosis I prefer open surgery as carotid-carotid bypass
Hi
if I well understand the restenosis was in the overlaping zone where there are two different materials in contact and a different radial force. It's very likely that these two factors have favored the neointimal iperplasia.
- Badges
- Science topic
- Similar topics
- Biological Science
- Anatomy
- Tissue