PMC9990767_01
Initial magnetic resonance angiography revealed severe stenosis of the right internal and external carotid artery on patient admission (white arrow).
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Magnetic resonance imaging (MRI) showed severe stenosis at the right carotid bifurcation [Figure 1].
(a) Lateral view of the right common carotid artery on a preoperative angiogram focused on the neck. (b) The stenosis of the right internal carotid artery was predilated with a 3 x 20 mm dilation balloon. (c) A 7 x 25 mm self-expandable carotid stent (CASPER Rx ) was placed. (d) After post-dilation, the angiogram revealed good revascularization.
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Digital subtraction angiography (DSA) revealed severe stenosis of the right ICS (North American Symptomatic Carotid Endarterectomy Trial, 70%) and near occlusion of the external carotid artery (ECA) [Figure 2a]. ICS was predilated with a 3 x 20 mm balloon (Coyote balloon dilatation catheter, 6 atm*30 s) [Figure 2b]. In addition, a 7 x 25 mm self-expandable carotid stent (CASPER Rx ) was poorly dilated [Figure 2c], and the stent was dilated twice by a balloon (4 x 30 mm and 4.5 x 30 mm Sterling balloon dilatation catheter). After post-dilation, DSA demonstrated that the most narrow area measured 2.4 mm [Figure 2d].
Computed tomography angiography (CTA) showed an occlusion of the right femoral artery after hemostasis. White arrow head denotes right femoral artery.
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Computed tomography angiography revealed occlusion of the right femoral artery after hemostasis on POD3 [Figure 3].
(a) MRI showed scattered infarction of the right cerebral hemisphere and (b) the occlusion of the right common carotid artery was (CCA) observed on angiography. (c) A patency of the distal part of the right internal carotid artery (cavernous portion) was confirmed on a preoperative angiogram.
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On POD12, left hemiplegia and dysarthria were suddenly observed (National Institute Health of Stroke Scale, scores 6), and MRI showed scattered infarctions of the right cerebral hemisphere and occlusion of the CCA [Figure 4a]. Just before the proximal part of the stent, occlusion of the right CCA was observed on angiography [Figure 4b]. Patency of the distal part of the right cavernous ICA was confirmed [Figure 4c].
Operative view. (a) The right common carotid artery, internal carotid artery, external carotid artery, and superior thyroid artery were clamped temporally before arteriotomy. (b) The carotid stent was cut with arteriotomy. (c) A thrombus in the stent was observed. (d) Compression marks due to the stent were observed on the intima of the blood vessel.
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Tokyo, Japan) was administered through drip infusion for 30 min before ICA clamping and ICA, STA, and ECA were temporarily clamped in order [Figure 5a]. The stent was cut with Potts-Smith angled scissors along the thickened endometrium [Figure 5b], and a thrombus in the stent was observed directly below [Figure 5c]. Compression marks due to the stent were observed on the intima of the blood vessels [Figure 5d] and a sufficient backflow was confirmed immediately from the distal declumped ICA.
Operative view. (a) An arteriotomy was also performed in the external carotid artery. (b) The artery was sutured continuously with 6-0 proline on both sides. (c and d) Histopathologically, a part of the intima and media was collected, and there was no evidence of plaque protrusion into the stent.
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T-shaped intraluminal shunt was inserted into the ICA and CCA, while arteriotomy was performed in the ECA, and the thickened intima was peeled off to confirm that patency had been reached [Figure 6a]. The temporary clamp was released in the same order, and the artery was sutured with 6-0 proline [Figure 6b]. A part of the intima and media was collected for histopathological analysis, and there was no evidence of plaque protrusion into the stent [Figures 6c and d].
(a) Postoperative MR imaging revealed no new cerebral infarction. (b) Preoperative MR angiography of the neck showed the patency of the right internal carotid artery (ICA) and external carotid artery (ECA).
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Postoperative head MRI revealed no new findings of cerebral infarction, and improvement in the depiction of ICA and ECA was noted [Figures 7a and b].