Asymptomatic carotid stenosis stenting

A 60-year-old male with a history of hypertension, dyslipidemia, COPD, coronary artery disease, and former alcohol abuse was referred for evaluation of a significant left carotid stenosis.

Recent imaging confirmed a > 70% stenosis with calcified ulceration in the left internal carotid artery, in the context of diffuse parietal disease and a Type I aortic arch. The patient was on dual antiplatelet therapy and had undergone cardiac arrhythmia ablation three months earlier.

Find out which revascularisation strategy was chosen and how the intervention was safely carried out in this high-risk profile.

Gustavo A. Basso

Leforte Hospital – São Paulo, Brazil

Part I - Case presentation

History

A 60 year-old male patient referred by the cardiologist
No previous TIA / stroke
Hypertension/ dyslipidemia/ heavy smoker - COPD/ CAD, former chronic alcoholic
PO cardiac arrhythmia ablation Dec/24’
Treatment: 💊 DAPT (Aspirin + Ticagrelor) + Statin + 4 classes of antihypertensives (angiotensin II receptor blocker twice a day, calcium channel blocker twice a day, beta blocker once a day, thiazide diuretic once a day).

Cardiac status: 65 % FE

Carotid duplex: diffuse parietal disease with left carotid stenosis > 70 % with calcified ulcer

Angio CT scan: diffuse parietal atherosclerosis on left carotid artery with stenosis > to 70% and ulceration. Type I arch.

Carotid treatment

Angio CT

pre-angiogram

Part II - Final strategy

According to the European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease¹, the management of carotid stenosis ranging from 60 % to 99 % is as follows:

Carotid treatment: In accordance with ESVS guidelines

Procedure

Right CFA puncture, 5F short sheath
Terumo 0,035 GW, Pigtail for arch angiogram / HH 5F Catheter to cannulate
Left CEA catheterisation, exchange GW for Amplatz floppy short tip 1 cm
Exchange catheter for long sheath 6F x 90 cm, positioned in left CCA (5.000UI IV heparin)
Filter protection preparation (Captur 6 mm = Spider),
Advance 0,014 GW through the ICA stenosis,
Deployed at a straight position above the lesion
PRE-Dilatation required? ➡️ Unnecessary for this case
MicroMesh stent C-GUARD 7 x 40 mm delivered on roadmapping
Post dilatation 6 x 20mm for stent deployment completude

⚠️ Atropine ready for injection in case of significant bradycardia

Carotid stenting treatment: pos Angiogram

post-angiogram

Day+1 discharge

Carotid stenting treatment: 90d Dupplex control

90-day duplex control

Day 0 at UCI

Reference:

European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease - Ross Naylor, Barbara Rantner, Stefano Ancetti, Gert J. de Borst, Marco De Carlo, Alison Halliday, Stavros K. Kakkos, Hugh S. Markus, Dominick J.H. McCabe, Henrik Sillesen, Jos C. van den Berg, Melina Vega de Ceniga, Maarit A. Venermo, Frank E.G. Vermassen - Eur J Vasc Endovasc Surg. 2023 - DOI: 10.1016/j.ejvs.2022.04.011