PMC8247661_01
(a) Diffusion-weighted image at initial presentation showing the right frontal insulo-opercular infarction. Sagittal image of CT angiogram of (b) the right and (c) the left carotid artery, showing mild stenosis on the right and severe stenosis on the left side (arrow). (d) CT without contrast medium of the neck, showing severe calcified carotid plaque on the left side (double arrows).
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Magnetic resonance imaging (MRI) of the brain revealed an acute infarction in the right frontal insuloopercular area [Figure 1a]. A computed tomography (CT) angiogram found bilateral carotid artery stenosis, which was more severe on the left side (right: 47%, left: more than 90%, on NASCET criteria), with the distal nontapering portions of the internal carotid artery serving as the reference segment [Figure 1b and c]. CT of the neck demonstrated non-circumferential but severe calcification of bilateral carotids [Figure 1d]. Before CAS, the transvenous cardiac pacemaker was placed through the left femoral vein, because the serious hemodynamic depression was expected due to severe calcified plaque [Figure 1d].
Lateral projection of the left carotid angiogram during CAS procedure. (a) Control angiogram before operation showing severe stenosis of the left internal carotid artery. (b) Proximal balloon protection (arrow) before stenting. (c) Final angiogram after stent deployment.
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The selective digital subtraction angiogram showed a severe stenosis of the left carotid artery [Figure 2a]. A self-expandable open-cell stent (4 x 40 mm, PRECISE Pro RX, Cordis Japan) was deployed successfully, with no post dilation [Figure 2c].
(a) Intraoperative and (b) postoperative cardiopulmonary monitoring chart. (a) For sedation, propofol was administered continuously, causing a gradual decrease in systolic blood pressure (sBP). Atropine was given intravenously, and increases in sBP and heart rate (HR) were confirmed. Balloon angioplasty with stent deployment was then conducted successfully. (b) About 45 min after ICU admission, severe circulatory depression developed, but recovery from it was accomplished immediately on cessation of propofol and administration of noradrenaline and dopamine. HR: Heart rate, NIBP: Non-invasive blood pressure, S: Systolic, D: Diastolic, M: Mean, SpO2: Percutaneous oxygen saturation, ICU: Intensive care unit.
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Blood pressure was decreased depending on the propofol infusion, which was managed by means of intermittent administration of 1 mg etilefrine [Figure 3a]. TTCP [Figure 3b].
Forest plots of predictors of periprocedural hemodynamic depression with statistical significance: (a) smoking, (b) calcification.
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