PMC10370511_01
Lateral-view right common carotid angiography. (A) Angiography on admission shows severe stenosis (arrow) with thrombus (arrowhead) at the origin of the right ICA. (B) Angiography on hospital day 7 shows complete disappearance of thrombus (arrow). ICA: internal carotid artery
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F1
Trial 90% stenosis at the origin of the right ICA, with thrombus observed on admission (Fig. 1A). The patient was immediately administered 300 mg of aspirin and 600 mg of clopidogrel as loading doses, and heparinization was started on admission. On hospital day 7, angiography showed complete disappearance of thrombus (Fig. 1B).
Preoperative axial-view MRA of the plaque with T1-weighted black blood method. Signal hyperintensity is evident at the origin of the right ICA (arrow). The black circle shows the ROI at the carotid plaque (mean signal intensity: 382.7) and the yellow circle shows the ROI in the muscle (mean signal intensity: 189.5). Signal intensity ratio is 2:1, suggesting the presence of unstable plaque. ICA: internal carotid artery; ROI: region of interest
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F2
T1-weighted imaging using the black blood method. The ratio of signal intensities for the sternocleidomastoid muscle and plaque was 1:2, suggesting unstable plaque (Fig. 2).
CAS using the CS to treat severe stenosis with unstable plaque at the origin of the right ICA. (A) Fluoroscopic image of protection device placement, with proximal protection provided by a Mo.Ma Ultra device (arrowhead) and distal protection by a FilterWire EZ (arrow). (B) An 8 mm x 30 mm CS is placed to cover the stenotic site (arrows). (C) Post-dilatation is performed using a 4 mm x 40 mm balloon catheter (arrow). (D) IVUS after stent placement. The isoechoic area in the vascular lumen indicates intraluminal PP (arrows). (E) A second CS (8 mm x 20 mm; arrows) is guided inside the first stent (arrowheads) and placed in a stent-in-stent manner. (F) After placement of the second stent, IVUS performed at the level of minimum lumen diameter confirms the absence of PP. (G) Lateral-view angiography of the right common carotid following additional second CS shows successful dilatation of the lesion without in-stent defect (arrow). CAS: carotid artery stenting; CS: CASPER stent; ICA: internal carotid artery; IVUS: intravascular ultrasonography; PP: plaque protrusion
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The patient showed no neurological symptoms and the procedure was completed (Fig. 3).