PMC10400897_01
Preoperative plaque images and postoperative MRI. (A) Preoperative plaque image by TOF. The plaque shows high intensity compared to the sternocleidomastoid muscle (blue arrowhead). (B) Preoperative plaque image by carotid duplex. The plaque appears low overall, and a linear echo-free space is seen in the plaque (red arrow). (C and D) The DWI images after the first surgery. A few tiny high-intensity spots can be seen (asymptomatic). (E and F) The DWI images after the second procedure. There are no additional lesions. TOF: time-of-flight
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The plaque had high intensity on time of flight of magnetic resonance imaging and low on carotid duplex (Fig. 1A and 1B), indicating the plaque was vulnerable. Although MRI at postoperative day (POD) 1 showed a few spots of high-intensity lesion in the diffusion weighted image (DWI) (Fig. 1C and 1D), the patient did not show any new neurological deficit. After the operation, the patient had no additional neurological deficits and MRI showed no additional lesions on DWI or any other sequences. (Fig. 1E and 1F).
DSA view. (A) DSA performed before the balloon dilation and stenting. Ulcer formation is detected (yellow arrow) and the narrowest region is placed at distal end of the plaque (blue arrowhead). (B) DSA after CAS. There is extra-stent contrast pooling, but ISTP is not detected. (C) DSA performed in the state of CCA occlusion at the second operation. ISTP is detected, not at the narrowest region (blue arrowhead) but at the ulcer site (red circle). (D) After aspiration, there is a slight residual ISTP, but the plaque is flattened and thrombosis does not occur (red circle). CAS: carotid artery stenting; ISTP: in-stent thrombosis or plaque protrusion
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After that, post-dilation was performed with the same 3 mm x 4 cm angioplasty balloon at 6 atm for 10 seconds. Although slight contrast pooling outside the stent remained, thrombotic tendency was not detected, and we completed the procedure (Fig. 2A and 2B). After placing the CCA occlusion balloon (8Fr OPTIMO EPD), the two plaques were detected by DSA and carotid duplex (Figs. 2C, 3C, and 3D). We completed the procedure without stent-in-stent development (Figs. 2D, 3E, and 3F).
Carotid duplex view. (A and B) The two mobile plaques are detected in the stent. (C and D) Two plaques before aspiration detected by intraoperative carotid duplex. (E) The residual plaque after aspiration. (F) The distal access catheter is clearly visualized by intraoperative carotid duplex. (G) The residual plaque at POD 1. POD: postoperative day
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The postoperative course appeared to be good, but carotid duplex at POD 6 detected two in-stent mobile plaques (3.6 mm x 4.5 mm and 2.0 mm x 1.6 mm) (Fig. 3A and 3B, respectively). After placing the CCA occlusion balloon (8Fr OPTIMO EPD), the two plaques were detected by DSA and carotid duplex (Figs. 2C, 3C, and 3D). We completed the procedure without stent-in-stent development (Figs. 2D, 3E, and 3F). Carotid duplex was performed at 1 day, 1 week, 1 month, and 3 months postoperatively; and fortunately, the residual tiny plaques did not increase from 1 day to 1 month (Fig. 3G) and disappeared by 3 months.
Macro- and microscopic findings of the aspirated plaques. Appearance is yellowish (A) and microscopically, atherosclerotic plaque with fibrin; aggregation of inflammatory cells, such as macrophages; and abundant cholesterol cleft (HE staining; original magnification, x20 [B], x200 [C]). HE: hematoxylin and eosin
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