Recanalizing an acutely occluded, symptomatic, previously stented carotid artery

Author: BEBEDJIAN Razmik

Find out how Dr. Razmik Bebedjian (FRCPC Neurologist Stroke and Interventional neuroradiology fellow University of Ottawa, Canada) treated a 68-year-old male patient suffering from an acutely occluded, symptomatic, previously stented carotid artery.

• Case

  HISTORY

  • ID: 68M, RHD. Independent at baseline from home with MRS 0.
  • PMH:
    • HTN
    • DLD
    • Smoker
    • CAD (PCI to LAD Oct 2020)
    • HFpEF
    • Severe Aortic Stenosis
    • PAD- Chronic occlusion of the RCI, Proximal II, and EI- Chronic occlusion of left SFA with significant infra popliteal disease- Moderate narrowing of the left EI, left CFA
    • CKD (baseline Cr 96)

   

  • CVA: Right MCA stroke Aug 2020
    • Presented with right MCA syndrome, high NIHSS
    • Good Aspects 10
    • CTA showed tandem disease in the distal right CCA- proximal ICA
    • Occlusion of the right M1

   

  IMAGING AUG 2020

  

   

  

   

  

   

  • CVA: Right MCA stroke Aug 2020
    • Did a great clinical recovery NIHSS 2 (dysarthria and mild ataxia)
    • Right CCA and ICA were stented with 2 carotid wall stent

   

  

   

  

   

  

   

  

   

   

   

  HISTORY OF RIGHT MCA STROKE

  • Discharged home with NIHSS 2
  • Continued to smoke after discharge
  • Jan 2021: Doppler showed focal narrowing at mid-segment of the stent with increased velocities
  • On DAPT since Oct 2020 (PCI then carotid stent)

   

  JAN 2021 FU DOPPLER

   

  

   

   

   

  SECOND PRESENTATION OCT 19-2021

  • LSN 11 AM.
  • SO: Left arm and leg weakness that resolved spontaneously by the time he presented to a community hospital 4:45 PM
  • Symptoms recurred at 5:15 PM
  • CTA done at the community hospital showed occlusion of the right CCA at the level of the stent

   

  

   

  

   

  COW AND EXTRA-CRANIAL VASCULATURE

  • Hypoplastic left vertebral artery
  • Dominant right vertebral artery
  • Occluded left ICA
  • Moderate stenosis of the left ECA
  • Occluded right CCA

   

  

   

  

   

  DECISION WHETHER TO INTERVENE OR NOT

  • NIHSS upon arrival to Ottawa was 0
  • Had 2 fluctuations in the community hospital
  • Had 3 fluctuations overnight in the NACU
  • The patient was kept in reverse Trendelenburg position in the ICU, started on IV fluids and pressers to keep sBP above 140mmHg

   

  HOSPITAL COURSE

  • NIHSS 0 at presentation on Oct 19
  • NIHSS 2 with left arm and leg drift on Oct 20 at 3 am, remained NIH 2 through the rest of the day on Oct 20
  • Echo showed large LV thrombus
  • The patient was started on continuous IV heparin in addition to the aspirin. Plavix was stopped.

   

  IN PATIENT CODE STROKE OCT 21-2021

  • 8:30 am: marked worsening of left-sided weakness predominantly affecting his left arm
  • NIH 7: with no antigravity in the left arm, drift of the left leg, left hemi-sensory neglect
  • sBP had remained stable 140-150s with no drop in BP.  
  • Pt had been in bed and not due to positional change

   

  

   

  SET UP

  • Balloon guide catheter
  • Flow gate, Merci
  • Balt
  • Cerebase
  • Infinity
  • Asahi Fubuki

  1. Left groin puncture- Amplatz wire
  2. 6F long sheath- Neuron Max
  3. 5F Vert over Advantage wire to catheterize the right CCA
  4. Advantage over Vert to cross the stent occlusion
  5. 4 X 40mm Mustang balloon
  6. Continuous aspiration through the Neuron Max

   

  

   

  

   

  

   

  • 100 mcg of nitroglycerin was given- improving spasm

   

  

   

  • 4 X 1.5cm cutting balloon

   

  

   

  

   

  • 6 X 20mm balloon angioplasty for the mid-segment at the 2 stent overlap location

   

  

   

  

   

  

   

  • After additional 100mcg of IA nitroglycerin

   

  

   

  

   

  IMMEDIATE COMPLICATIONS

  1. Bradycardia and brief episodes of asystole occurred at the time of the aggressive angioplasty
  2. Intracranial iatrogenic spasms treated with nitroglycerin
  3. Volume loss and hypotension at the end of the procedure: volume repletion
  4. Iatrogenic dissection and right M1 thromboembolism: treated with a combined approach

   

  POST-TREATMENT IMAGING

   

  

   

  

   

  

   

  OUTCOME

  • The patient was discharged home after a week on aspirin and rivaroxaban
  • NIHSS of 1 for mild left leg weakness
  • MRS 1