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CLINICAL IMPACT: Digital subtraction angiography (DSA) has traditionally been considered an effective method for visualizing carotid free-floating thrombus (CFFT), but it falls short in providing detailed structures of the lumen and the composition of thrombi, making it challenging to determine the etiology. Intravascular optical coherence tomography (OCT) is a valuable adjunct to DSA that can precisely evaluate the characteristics of the intrinsic vessel wall and accurately distinguish between red and white thrombus, providing clues to the etiology of CFFTs. Moreover, OCT not only precisely determined the scope of a floating thrombus but also provided guidance for decision-making in endovascular treatment.
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We present the case of an 80-year-old man who underwent a subclavian-to-distal internal carotid artery bypass with a reversed saphenous vein due to symptomatic in-stent restenosis, following a carotid endarterectomy 20 years ago and carotid artery stenting 10 years ago. The patient presented with right-sided hemiparesis and dysarthria. Imaging suggested in-stent restenosis of the internal carotid artery stent. He was also found to have stenosis of the common carotid artery origin stent. An initial transfemoral attempt by interventional radiology was unsuccessful. Due to the stenosed common carotid artery origin stent, a common carotid-to-internal carotid artery bypass was not feasible. Therefore, a subclavian-distal carotid artery bypass with a reversed saphenous vein was performed. He did well in the postoperative period and has been seen in the clinic since. Surveillance ultrasound demonstrated a patent graft with non-stenotic proximal and distal anastomoses. We include an in-depth review of the management of recurrent carotid artery stenosis as well.
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OBJECTIVE: Computed tomography angiography (CTA) is a well-established diagnostic modality for carotid stenosis. However, false-positive CTA results may expose patients to unnecessary procedural complications in cases where surgical intervention is not warranted. We aim to assess the correlation of CTA to digital subtraction angiography (DSA) in carotid stenosis and characterize patients who were referred for intervention based on CTA and did not require it based on DSA. METHODS: We retrospectively reviewed 186 patients who underwent carotid angioplasty and stenting following preprocedural CTA at our institution from April 2017 to December 2022. RESULTS: Twenty-one of 186 patients (11.2%) were found to have <50% carotid stenosis on DSA (discordant group). Severe plaque calcification on CTA was associated with a discordant degree of stenosis on DSA (LR+=7.4). Among 186 patients, agreement between the percentage of stenosis from CTA and DSA was weak-moderate (r2=0.27, P<0.01). Among concordant pairs, we found moderate-strong agreement between CTA and DSA (adj r2=0.37) (P < 0.0001). Of 186 patients, 127 patients had CTA stenosis of ≥70%, and 59 had CTA of 50%-69%. Correlation between CTA and DSA in severe CTA stenosis was weak (r2=0.11, P<0.01). CONCLUSIONS: In patients with stenosis found on CTA, over 88% also had stenosis on DSA, with this positive predictive value in line with previous studies. The percent-stenosis value from CTA and DSA was weakly correlated but does not affect the overall clinical judgement of stenosis. Severe calcification found on CTA may potentially indicate nonstenosis on DSA.
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Angiografía de Substracción Digital , Estenosis Carotídea , Angiografía por Tomografía Computarizada , Humanos , Angiografía de Substracción Digital/métodos , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Femenino , Masculino , Anciano , Angiografía por Tomografía Computarizada/métodos , Estudios Retrospectivos , Persona de Mediana Edad , Anciano de 80 o más Años , Stents , Angioplastia/métodos , Angiografía Cerebral/métodosRESUMEN
Background and objective: carotid artery stenosis contributes significantly to ischemic strokes, with management options including carotid endarterectomy (CEA) and carotid artery stenting (CAS) ischemic stroke risk can be reduced. Controversies persist regarding their efficacy and factors influencing complications, and understanding the relationship between atherosclerotic plaque characteristics and stent restenosis after CAS is crucial. Methods: we conducted a retrospective study involving 221 patients who underwent CAS for symptomatic or asymptomatic carotid artery stenosis. Comprehensive assessments of plaque morphology were performed using contrast-enhanced ultrasound (CEUS) before CAS. Patient demographics, including smoking status and diabetes, were also recorded. Stent restenosis was diagnosed using various imaging modalities, including ultrasound, angiography, and digital subtraction angiography (DSA). Results: plaque analysis using CEUS revealed a significant association between plaque grade and restenosis incidence (p < 0.001), particularly with grade 0 (11.1%) and grade 2 plaques (66.7%). Smoking was notably associated with plaque vascularization and restenosis (p < 0.001), while diabetes did not significantly impact plaque characteristics or restenosis risk (p > 0.05). The mean duration of restenosis was 17.67 months. Stenting was the most frequent treatment modality for restenosis (70.6%). However, no significant relationship was found between restenosis type and plaque morphology (p = 0.268). Furthermore, while no clear relationship was observed between plaque morphology and the type of restenosis, our findings underscored the importance of plaque characterization in predicting post-CAS outcomes. Conclusions: this study highlights the utility of CEUS in predicting stent restenosis following CAS. There was a significant association between stent restenosis within 12-24 months after the carotid stenting procedure and an elevated grade of plaque vascularization. Moreover, one of the main factors possibly determining the grade of plaque vascularization was smoking. Further research is warranted to elucidate the underlying mechanisms and refine risk stratification in this patient population.
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Estenosis Carotídea , Medios de Contraste , Placa Aterosclerótica , Stents , Ultrasonografía , Humanos , Estudios Retrospectivos , Masculino , Femenino , Anciano , Stents/efectos adversos , Estenosis Carotídea/cirugía , Estenosis Carotídea/diagnóstico por imagen , Placa Aterosclerótica/diagnóstico por imagen , Persona de Mediana Edad , Ultrasonografía/métodos , Arterias Carótidas/diagnóstico por imagen , Arterias Carótidas/cirugía , Angiografía de Substracción Digital/métodos , Anciano de 80 o más Años , Factores de RiesgoRESUMEN
BACKGROUND: Transcarotid artery revascularization (TCAR) is growing in popularity. Although major clinical end-points such as stroke rate and mortality are well-known, patient reported outcomes such as pain, and length of stay are among the purported benefits that are as yet untested. We sought to determine if there are differences in pain and other clinical outcomes when comparing carotid endarterectomy (CEA) and TCAR. METHODS: We performed a retrospective review of 326 patients undergoing TCAR (n = 50) or CEA (n = 276) from 2019-2023. Primary outcomes of interest were maximum pain numeric rating scales (NRS) reported in the post-anesthesia care unit (PACU) and on postoperative days (POD) zero and 1, and oral morphine milligram equivalents (OMMEs) received intraoperatively through POD1. Secondary outcomes included length of stay (LOS), complications, and 30-day emergency department (ED) returns/readmissions. RESULTS: Fifty TCAR and 150 CEA patients were included in the propensity score matched cohorts. TCAR patients reported lower pain-NRS in PACU (P < .001) and on POD0 (P = .002), but similar pain scores on POD1 (P = .112). Postoperatively, TCAR patients were less likely to receive opioids (52% vs 75.3%, P = .003) and received less OMME from PACU through POD1 (12.8 ± 16.2 vs 23.2 ± 27.2, P = .001). After adjusting for age, sex, BMI, prior chronic opioid use, and prior carotid surgery, TCAR patients were approximately 70% less likely to receive post-operative opioids. No significant differences in LOS, 30-day ED returns/readmissions, or complications were observed between groups. CONCLUSIONS: Compared with CEA, patients undergoing TCAR reported lower pain scores and consumed fewer narcotics overall. However, the absolute difference was modest, and pain scores were low in both cohorts. Differences in pain and post-operative narcotic use may be of less importance when deciding between TCAR and CEA. Total non-opioid protocols may be feasible in both approaches.
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Endarterectomía Carotidea , Tiempo de Internación , Dimensión del Dolor , Dolor Postoperatorio , Humanos , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Masculino , Femenino , Estudios Retrospectivos , Dolor Postoperatorio/etiología , Dolor Postoperatorio/diagnóstico , Anciano , Resultado del Tratamiento , Factores de Tiempo , Persona de Mediana Edad , Factores de Riesgo , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Analgésicos Opioides/uso terapéutico , Anciano de 80 o más Años , Medición de Riesgo , Enfermedades de las Arterias Carótidas/cirugía , Enfermedades de las Arterias Carótidas/mortalidad , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Estenosis Carotídea/cirugía , Estenosis Carotídea/mortalidad , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagenRESUMEN
OBJECTIVE: Atherosclerotic carotid artery stenosis is a significant contributor to ischemic strokes, and carotid artery stenting (CAS) has emerged as a pivotal treatment option. However, in-stent restenosis (ISR) remains a concern, impacting the long-term patency of CAS. This study aimed to investigate the predictive value of non-traditional lipid profiles, including the atherogenic index of plasma (AIP), in ISR development. METHODS: This retrospective single-center study involved patients presenting at a tertiary healthcare facility with severe carotid artery disease between 2016 and 2020 who subsequently underwent CAS. A total of 719 patients were included in the study. The study cohort was divided into ISR and non-ISR groups based on restenosis presence, confirmed by angiography following ultrasonographic follow-up assessments. Non-traditional lipid indices, such as AIP, atherogenic index (AI), and lipoprotein combined index (LCI), were evaluated along with traditional risk factors. RESULTS: During a 24-month follow-up, ISR occurred in 4.03% of patients. To determine the predictors of restenosis, three different models were constructed in multivariate analysis for non-traditional lipid indices. Multivariate analysis revealed AIP as a robust independent predictor of ISR (OR: 4.83 (CI 95 % 3.05-6.63, p < .001). Notably, AIP demonstrated superior predictive accuracy compared to AI and LCI, with a higher Area Under the Curve (AUC) of 0.971. CONCLUSION: Non-traditional lipid profiles, especially AIP, were found to be associated with an increased risk of ISR and may serve as predictors of ISR in patients undergoing CAS.
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AIMS: To describe through emblematic images rare but clinically relevant carotid artery stenting complications that occurred at two high-volume centres for carotid artery stenting (CAS). BACKGROUND: CAS is an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis in patients judged to be at high risk for CEA. CAS complications range between 1 and 9% and are higher in older patients complaining of neurological symptoms at the time of presentation. Besides periprocedural or early-after-procedure stroke, which remains the true Achilles' heel of CAS, other dramatic complications might compromise the clinical outcomes of this procedure. METHODS: Five infrequent complications, out of more than 1000 CAS performed in the years 2016-2021, have been described. RESULTS: Among CAS complications, acute carotid stent thrombosis, rescue retrieval of a disconnected distal cerebral embolic protection device, plaque prolapse after carotid stenting, cerebral hyperperfusion syndrome (CHS), and radial artery long sheath entrapment requiring surgical intervention were found to account for 0.3% of the total number of procedures performed by operators with high CAS volume. CONCLUSIONS: Unusual CAS complications may infrequently occur, even in hands of expert operators. To know how to deal with such complications might help interventionalists to improve CAS performance.
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Carotid free-floating thrombus (FFT) is a rare condition in patients with acute ischemic stroke. Recently, endovascular therapy for carotid FFT has been increasingly reported, but the strategy has not yet been established. We report a case of an acute stroke patient with a carotid FFT, who was successfully treated with a combination of the direct aspiration first-pass technique (ADAPT) and the Embotrap III (Cerenovus, Irvine, CA), specifically designed to prevent distal embolization. We propose the utility of distal embolic protection with Embotrap III for the treatment of patients with carotid FFT. A 71-year-old man who presented with sudden left hemiparesis was admitted to our hospital. Ultrasonography on admission revealed severe stenosis and an FFT at the origin of the right internal carotid artery. Thrombectomy with an aspiration catheter, accompanied by a stent retriever with distal basket Embotrap III for distal protection, was performed. After the FFT was safely aspirated, a carotid Wallstent (Boston Scientific, Marlborough, MA) was deployed in the stenosis. Follow-up ultrasonography showed neither FFT nor in-stent protrusion. The patient did not experience recurrence, as per clinical or radiological findings, and was discharged on day 11 without any neurological deficits. Embotrap III may be useful for a patient with a carotid FFT as distal protection during mechanical thrombectomies.
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OBJECTIVES: The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR. METHODS: Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors. RESULTS: A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke. CONCLUSIONS: Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal. CLINICAL IMPACT: The ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.
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The study aims to review the sex differences with respect to transient ischemic attack (TIA)/stroke and death in the perioperative period and on long-term follow-up among asymptomatic patients treated with carotid stenting (CAS) in the vascular quality initiative (VQI). All cases reported to VQI of asymptomatic CAS (ACAS) patients were reviewed. The primary end point was risk of TIA/stroke and death in the in-hospital perioperative period and in the long-term follow-up. The secondary end point was to evaluate predictors of in-hospital perioperative TIA/stroke and mortality on long-term follow-up after CAS. There were 22,079 CAS procedures captured from January 2005 to April 2019. There were 5,785 (62.7%) patients in the ACAS group. The rate of in-hospital TIA/stroke was higher in female patients (2.7 vs. 1.87%, p = 0.005) and the rate of death was not significant (0.03 vs. 0.07%, p = 0.66). On multivariable logistic regression analysis, prior/current smoking history (odds ratio = 0.58 [95% confidence interval or CI = 0.39-0.87]; p = 0.008) is a predictor of in-hospital TIA/stroke in females. The long-term all-cause mortality is significantly higher in male patients (26.9 vs. 15.7%, p < 0.001). On multivariable Cox-regression analysis, prior/current smoking history (hazard ratio or HR = 1.17 [95% CI = 1.01-1.34]; p = 0.03), coronary artery disease or CAD (HR = 1.15 [95% CI = 1.03-1.28]; p = 0.009), chronic obstructive pulmonary disease or COPD (HR = 1.73 [95% CI = 1.55-1.93]; p < 0.001), threat to life American Society of Anesthesiologists (ASA) class (HR = 2.3 [95% CI = 1.43-3.70]; p = 0.0006), moribund ASA class (HR = 5.66 [95% CI = 2.24-14.29]; p = 0.0003), and low hemoglobin levels (HR = 0.84 [95% CI = 0.82-0.86]; p < 0.001) are the predictors of long-term mortality. In asymptomatic carotid disease patients, women had higher rates of in-hospital perioperative TIA/stroke and a predictor of TIA/stroke is a prior/current history of smoking. Meanwhile, long-term all-cause mortality is higher for male patients compared with their female counterparts. Predictors of long-term mortality are prior/current smoking history, CAD, COPD, higher ASA classification of physical status, and low hemoglobin level. These data should be considered prior to offering CAS to asymptomatic female and male patients and careful risks versus benefits discussion should be offered to each individual patient.
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BACKGROUND: While noninvasive imaging is typically used during the initial assessment of carotid artery disease, digital subtraction angiography remains the gold standard for evaluating carotid stent thrombosis and stenosis (Krawisz in Cardiol Clin 39:539-549, 2021). This case highlights the importance of digital subtraction angiography for assessing carotid artery stent patency in place of non-invasive imaging. CASE PRESENTATION: We present a 61-year-old African American male patient with a history of right cervical internal carotid artery dissection that was treated with carotid artery stenting and endovascular thrombectomy, who developed recurrent right hemispheric infarcts related to delayed carotid stent thrombosis. Digital subtraction angiography found multiple filling defects consistent with extensive in-stent thrombosis not clearly observed with magnetic resonance angiography. Etiology was likely secondary to chronic antiplatelet noncompliance. Therefore, the patient was treated medically with a heparin drip, and dual antiplatelet therapy (dAPT) was restarted. At 1-month follow-up the patient did not report new motor or sensory deficits. CONCLUSION: In the setting of delayed carotid stent thrombosis secondary to antiplatelet noncompliance, digital subtraction angiography may play an essential diagnostic role for early identification and determination of the most appropriate treatment.
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Estenosis Carotídea , Trombosis , Humanos , Masculino , Persona de Mediana Edad , Stents/efectos adversos , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Angiografía Cerebral , Trombosis/diagnóstico por imagen , Trombosis/etiología , Arteria Carótida Interna/diagnóstico por imagen , Angiografía de Substracción DigitalRESUMEN
Chronic carotid total occlusion (CCTO) is a known cause of ischemic stroke and transient ischemic attack. Symptomatic CCTO is associated with up to 30% risk of recurrent ischemic stroke, despite optimal medical treatment. Notably, a randomized controlled trial reported that previous surgical management did not improve the overall prognosis of these patients. Endovascular treatment of CCTO has been proposed as a feasible strategy to re-establish cerebral perfusion in symptomatic patients. However, its use is controversial and not supported by evidence from randomized clinical trials. Recently, a meta-analysis reported a reasonably high procedural success without an excess periprocedural complication rate, but several steps are needed before the procedure is mature enough to be tested in randomized controlled trials. This review highlights the developments in the endovascular recanalization of CCTO and emphasizes key steps towards standardizing the procedure.
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Background: As there is still no consensus on the treatment of carotid stent thrombosis (CST), we would like to describe our experience with the revascularization of CST by mechanical thrombectomy. Methods: We retrospectively studied patients who underwent mechanical thrombectomy after CST at Xuzhou Municipal First People's Hospital and Xuzhou Central Hospital between January 2020 and November 2022. The results of the procedures, complications, and clinical and imaging follow-up were recorded. Results: A total of six patients were included in this study. The stenosis grade before stent implantation was ≥85% in all patients, and the stenosis length ranged from 7 to 20 mm. Patients experienced CST within 6 days to 45 months after carotid artery stenting (CAS); the median admission on the National Institutes of Health Stroke Scale (NIHSS) at CST was 12 (range 8-25). Mechanical thrombectomy was successfully performed in all patients. There was no periprocedural death, and the modified Rankin Scale (mRS) at the 3-month follow-up was 0-2. All patients showed recovery from their neurological deficits. Conclusion: The treatment of symptomatic CST with mechanical thrombectomy resulted in satisfactory clinical outcomes. This regimen could be effective and safe, and future prospective and randomized studies are warranted.
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An isolated spontaneous common carotid artery (CCA) dissection is an extremely rare cause of stroke, and standard treatment guidelines are not yet established. This case report presents a rare case of isolated spontaneous CCA dissection but with typical and obvious radiological findings, and it could be informative and educational to clinicians. Telescoping multiple carotid stents can be a feasible treatment option for this case with recurrent ischemia due to a long segment dissection.
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Allergic contact dermatitis is a common manifestation in individuals who have a contact hypersensitivity to nickel. Direct exposure to nickel triggers an adaptive immune response that mediates a localized inflammatory reaction of the skin, typically resulting in an erythematous and pruritic rash at the site of contact. We present a distinct case in which nickel was systemically introduced via a carotid stent into an individual with an unidentified allergy to nickel. This case emphasizes the potentially life-threatening risks associated with implantable hardware containing metals, such as nickel. Moreover, this case highlights the potential benefit that screening for metal allergies may have before surgically implanting permanent metal-based devices.
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Objective: Plaque protrusion (PP) during carotid artery stenting (CAS) is considered to be associated with periprocedural ischemic stroke. A new double-layer micromesh stent, the CASPER stent (CS), was approved for use in Japan in 2020. The expectation is that this micromesh stent system will reduce the risk of PP, but we report a case of PP during CAS despite the use of a CS. Case Presentation: An 87-year-old man presented with left hemiparesis. MRI showed right brain infarction and angiography showed right internal carotid artery stenosis with thrombus. Follow-up angiography after medical treatment showed that thrombus disappeared. We therefore performed CAS for right internal carotid artery stenosis with unstable plaque. CAS was performed under local anesthesia with Mo.Ma Ultra and FilterWire EZ protection using a CS placed to sufficiently cover the stenotic region. Conservative post-dilatation was then performed. Intravascular ultrasonography (IVUS) after post-dilatation showed the presence of PP. A second CS was then added using the stent-in-stent technique. No postoperative neurological abnormalities were found and the patient was discharged without postoperative complications. No stroke or restenosis has been observed as of 16 months after CAS. Conclusion: PP can occur even when CAS is performed using the CS for carotid artery stenosis with unstable plaque. The importance of checking for PP using IVUS is suggested.
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Open surgery is the gold standard for treating common and deep femoral arterial lesions. Nevertheless, significant data have emerged in recent years supporting an endovascular strategy for this peculiar anatomic region, despite certain disadvantages, including the requirement for strong compression resistance and excellent flexibility and conformability when stents are implanted. We present a case of critical limb ischemia due to total common and deep femoral arteries occlusion after endarterectomy that resulted in a very tapered lesion. It was successfully treated with percutaneous angioplasty and off-label application of an interwoven nitinol Roadsaver carotid artery stent, which demonstrated good adaptability.
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Introducción: Cuando la arteria cerebral posterior se origina desde la arteria carótida interna con un segmento P1 ausente, se denomina arteria cerebral posterior de origen fetal (ACPF). No está claro si la ACPF aumenta el riesgo de ictus isquémico agudo, y el tratamiento endovascular del ictus isquémico agudo debido a la oclusión aguda de la ACPF no está bien establecido. Caso clínico: Presentamos un caso de ictus isquémico agudo debido a la oclusión en tándem de la arteria carótida interna y la arteria cerebral posterior fetal ipsilateral tratado con éxito mediante la colocación de una endoprótesis en la lesión proximal y trombectomía mecánica de la lesión distal, con excelentes resultados neurológicos y funcionales. Conclusión: Aunque se necesitan más investigaciones para determinar el mejor tratamiento de estos pacientes, el tratamiento endovascular de la oclusión de la arteria cerebral posterior fetal es factible.(AU)
Introduction: When the posterior cerebral artery arises from the internal carotid artery with an absent P1 segment, it is called fetal posterior cerebral artery (FPCA). It is unclear whether FPCA increases the risk of acute ischemic stroke, and the endovascular treatment of acute ischemic stroke due to acute occlusion of FPCA is not well established. Case report: We report a case of acute ischemic stroke due to tandem occlusion of internal carotid artery and ipsilateral fetal posterior cerebral artery treated successfully with acute stenting of proximal lesion and mechanical thrombectomy of distal lesion with excellent neurological and functional outcomes. Conclusion: Although further investigations are needed to determine the best treatment of these patients, endovascular treatment of fetal posterior cerebral artery occlusion is feasible.(AU)
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Humanos , Masculino , Anciano , Accidente Cerebrovascular , Arteria Cerebral Posterior/cirugía , Arteria Carótida Interna , Procedimientos Endovasculares , Trombectomía , Pacientes Internos , Examen Físico , Neurología , Enfermedades del Sistema Nervioso , Prótesis e ImplantesRESUMEN
An 84-year-old patient developed immediate thrombosis of his carotid stent in recovery after transcarotid artery revascularization. In the present report, the technical details about intraoperative management for neurovascular rescue using the transcarotid artery revascularization flow-reversal system are described. The patient was determined to have clopidogrel resistance. Intraoperative medical management is also discussed. The current alternative intravenous and oral antiplatelet therapies such as glycoprotein IIb/IIIa and P2Y12 inhibitors are explored. The debate regarding preoperative antiplatelet resistance testing remains ambiguous, and increasing studies have demonstrated the safety and efficacy of alternatives to clopidogrel. Despite an unpredictable and devastating complication, the patient's outcome was successful using contemporary strategies.