PMC4754475_01
Digital subtraction angiogram shows eccentric, short segment plaque in the internal carotid artery next to the carotid bulb (a). After placing a protection filter (Emboshield NAV6), a covered stent (Direct Stent) was deployed to cover the plaque fully (b). In (c), angiogram shows no residual stenosis following both the insertion of a tapered, closed-cell stent (X-act) covering the covered stent and extending from the common to the internal carotid artery and the dilation of a 5 mm balloon. The stents are clearly visible in (d). Follow-up angiogram performed at the 6th (e) month shows no restenosis but minimal intimal hyperplasia inside the stents. The hyperplasia inside the stents is seen unchanged in the 12th-month angiogram (f).
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fig1
Diagnostic angiograms obtained under local anesthesia showed 75% stenosis consistent with the Doppler US and MRA (Figure 1). A balloon-expandable stent graft (ePTFE polymer coated) 5 x 13 mm in size (Direct Stent-Stent Graft, InSitu Technologies , Inc., Minnesota, USA) was deployed inside the proximal part of the ICA to cover and squeeze the plaque between the stent and the vessel wall, without covering the orifice of the external carotid artery. After performing angiography, a tapered, closed-cell carotid stent 9-7 x 30 mm in size (X-Act, Abbott, Redwood City, CA, USA) was implanted and a 5 x 20 mm monorail balloon was inflated inside the stents in the ICA part, both for proper apposition of the proximal and distal ends of the covered stent, for full opening of the stenosis without leaving any residue (Figures 1(a)-1(d)). The patient was neurologically symptom-free on follow-up, and Doppler US performed in the 1st, 3rd, and 6th months and catheter angiography performed in the 6th and 12th months showed no in-stent stenosis but minimal intimal hyperplasia inside the stent (Figures 1(e) and 1(f)).