Carotid stenosis: the athero-mystery

An asymptomatic 61-year-old woman, hypertensive, dyslipidemic, and obese, was diagnosed with a critical subocclusive stenosis at the ostium of the right internal carotid artery.

Imaging revealed a straight, non-tortuous vessel without atheromatous plaque, suggesting an actinic origin related to previous breast cancer radiotherapy. The patient had undergone bilateral mastectomy earlier in 2025 and was on antihypertensive, statin, and antiplatelet therapy.

The question now arises: in such a context, what is the most appropriate treatment approach?

Gustavo A. Basso

Leforte Hospital – São Paulo, Brazil

Part I - Case presentation

A 61-year-old woman, asymptomatic, with NO previous TIA / STROKE
Obese, hypertensive, with dyslipidemia, and undergoing oncological treatment for breast cancer
Prior radiotherapy and recent bilateral mastectomy (January 2025)
💊 anti-hypertensives (3 classes), statin, aspirin
Cardiac status: 73 % FE
Duplex: critical subocclusive stenosis at the ostium of the right internal carotid artery
Angio CT: confirmed straight artery, no tortuosity, and without atheromatous plaques. Type I arch.

→ Hypothesis: actinic stenosis

NO atheromatous plaques

Management of "average risk" patient with asymptomatic carotid stenoses with best medical therapy (BMT), carotid endarterectomy (CEA), and/or carotid artery stenting (CAS).

Recommendations regarding the management of "average risk" patient with asymptomatic carotid stenoses with best medical therapy (BMT), carotid endarterectomy (CEA), and/or carotid artery stenting (CAS).

Part II - Final strategy

Percutaneous approach

Right CFA puncture, 5F short sheath
GW, Pigtail / Simmons 1 5F catheter
Right CEA catheterisation, exchange GW for Amplatz floppy short tip 1 cm
Exchange catheter for long sheath 6F x 90cm, positioned at CCA
Prepare the Filter 6 protection, advance 0,014 GW through the lesion at CIA, deployed at a straight position
Then, deploy the Open cell Nitinol Stent 6 x 30 mm on roadmap
Post-dilatation balloon 5 x 20 mm. Just to remodelate the stent (Atropyne was necessary ⚠️)
Retrieve the filter
Final angiogram: exactly the same as pre., BUT there was no flow in the right ICA from release to removal of the cerebral protection filter 😬💔
Closure device

video

^{Percutaneous approach steps}