Severe carotid artery stenosis associated with contralateral carotid occlusion

In this case, a 72-year-old man with an extensive history of cardiovascular interventions is admitted for supra-aortic trunk angiography after duplex ultrasound revealed sub-occlusion of the right internal carotid artery and critical stenosis of the left.

The challenge lies in determining whether endovascular revascularisation is suitable, and if so, which embolic protection device and stent would be the safest and most effective choice!

Paolo Sbarzaglia

Cotignola, Italy

Fausto Castriota

Part I - Case presentation

The patient is a 72-year-old male.

CVRF: obesity (BMI 34,06 Kg/m²), HTN, former smoker, T2DM

Medical history:

CAD → PCI (w/DES) of right coronary artery (2014)
2018 → PTA (w/stent) of right and left iliac axes, and PTA of left SFA
2024 → PTA (w/stent) of left common iliac artery and PTA of the left fem-pop axis
April 2025 → Supra-aortic trunks duplex ultrasound → sub-occlusion of RICA and critical stenosis (80 %) of LICA.

Admitted at our institution for supra-aortic trunks angiography

Supra-aortic trunks angiography

Type 1 aortic arch

Slow left hemisphere circulation with contralateral and posterior compensation

Functional occlusion of LICA partially compensated through slow antegrade flow and LECA flow

Right carotid axis

Severe bulb calcification, severe calcified stenosis of the RICA, and pseudo-occlusion of RECA. Severe tortuosity of right internal carotid distally to stenosis