PMC8458646_01
Non-invasive assessment. Doppler ultrasound (US, left side) and computed tomography (CT, right side) volume rendering CT angiography of the patient. Arrow indicates the lumen collapse distal to the stent.
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Doppler ultrasound (US) showed a peak systolic velocity (PSV) of 6.81 m/s that coped well with in-stent sub-occlusion of the right ICA with distal lumen collapse on computed tomography angiography (CTA) (Figure 1).
Periprocedural carotid artery stenting step 1. Baseline right internal carotid artery (ICA) carotid in-stent restenosis (CISR) (A). 6F Destination Sheath positioned below the stent (B). Right ICA abrupt occlusion after predilation (C). Right ICA re-opening after aspiration (D). Close up of the Distal ICA (circle) after reopening (E, upper part) and close up of filter devise (E, lower part). Final digital subtraction angiography (DSA) after drug-coated balloon (DCB) inflation and filter retrieval (F).
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Baseline digital subtraction angiography (DSA) confirmed a sub-occlusive (95% DS), long CISR (Figure 2A). A 6F 90-cm-long Destination Sheath (Terumo, Tokyo, Japan) loaded on a 0.035" standard wire with a "reshaped tip" was positioned below the stent (Figure 2B). After predilation with a cutting balloon, 4 x 10 mm, abrupt ICA in-stent occlusion occurred (Figure 2C). The subsequent DSA imaging showed a wide patent stent with a filling defect close to the filter basket (Figures 2D,E). Final angiography after filter retrieval (no debris found) showed a good in-stent recanalization result with brisk contrast run-off in both external carotid artery (ECA) and ICA (Figure 2F).
Periprocedural carotid artery stenting step 2. Intracranial PA view showing middle cerebral artery (MCA) tract 1 occlusion (white arrow). Black arrows indicate the fetal posterior multiplanar reconstruction cerebral artery (FPCA) and the anterior cerebral artery (ACA) (A). Leptomeningeal collateral filling of distal MCA tract (white arrows, B). Whisper coronary wire (0.014") in the right MCA (C). Microcatheter (black arrows indicating proximal and distal microcatheter markers) positioned distal to the occlusion and angiographic test (D). Temporary reperfusion after aspiration (E). Failure to retrieve thrombus with a 3-mm Spider Filter (F). Coronary drug-eluting stent (DES) positioning (G). Reperfusion of the right MCA after stent-postdilation (H, asterisk: lenticulostriate arteries. Arrow indicates lumen reduction of the distal ICA lumen).
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Distal MCA was filled by leptomeningeal collaterals, which were visible on the late arterial frame (Figures 3A,B). Having removed the wire, the correct positioning of the wire was checked with contrast injection (Figures 3C,D). Aspiration was attempted with the 6F Export catheter obtaining only transient reperfusion of the distal vessel (Figure 3E). We tried to mechanically retrieve the thrombus with a 3-mm-diameter SpiderRx filter (Medtronic, Santa Rosa, CA, USA) opened distally and pulled back through the occlusion as a "trawl fishing" maneuver (Figure 3F). A Resolute Onyx drug-eluting coronary stent 2.5 x 18 mm (Resolute, Medtronic, Santa Rosa, CA, USA) was positioned and post-dilated allowing brisk distal vessel reperfusion and patient neurological improvement (Figures 3G,H).
Periprocedural carotid artery stenting step 3. Distal ICA dissection with intramural hematoma and lumen narrowing. Post-reperfusion right ICA angiography. Numbers refer to IVUS images shown in frames B,C) (A). IVUS frames 1 and 5 refer to the beginning and end of the intramural hematoma (B). IVUS frames 2-3-4 refer to the true intramural hematoma distribution (C). Following 7 x 20-mm PrecisePro stent positioning (arrow, D). Final DSA (arrow: residual intramural hematoma, E).
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An IVUS run was performed that confirmed this hypothesis and guided the positioning of an additional 7 x 20-mm PrecisePro stent out of the carotid canal (Figures 4A-C) to seal the dissection (Figures 4D,E).
CT angiography and transcranial Doppler at 1-year follow-up. Left side: Patency of the three stents by multiplanar reconstruction with maximum intensity projection in the sagittal plane (upper image) and axial plane at the level of Willis circle (lower image). Right side: Upper strip: average peak systolic velocity in the left and right (target vessel) MCA. The right MCA PSV is 79 cm/sec indicating a <50% in-stent restenosis. Middle strip: Breath holding test. Left MCA breath holding index 0.82 and right breath holding index 0.75 (normal value >0.69). Lower strip: hyperventilation test: Left MCA average PSV reduction 51%. Right MCA average PSV reduction 40%.
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Both Doppler US and carotid CT angiography showed wide patency of the three stents at 1-year follow-up (Figure 5).