Use of MR imaging of the vessel wall for carotid stent treatment planning

Clinical background

• 55-year-old male patient
• Medical history:
  • NPC treated with radio TX 20 years ago
  • Hypertension
  • Hyperlipidemia
• Right eye amaurosis fugax (resolved)
• Left hand paresthesia (resolved)

Investigations

•  Ophthalmology - occlusion of the RE branch artery
•  MRI - No infarction. Occlusion of the left ICA
•  CT Angiogram
  • Left ICA occluded at origin
  • Multifocal stenosis of the right CCA. Severe stenotic segment in the distal CCA

CT angiogram

CTA shows:

• Severe stenosis at the distal right CCA
• Moderate multifocal stenosis at the proximal right CCA
• Occluded left ICA

MRI of the vessel wall

•  MRI of the vessel wall shows high-risk plaque features (intraplaque haemorrhage) in the proximal right coronary artery.
•  Discussion with neurologist and patient. Decision to stent BOTH areas: severe stenosis at distal R CCA and moderate stenosis with high risk plaque at proximal R CCA.
•  Without VW MRI, we may choose to treat only the area of severe stenosis (distal CCA).
• The use of MRI to identify high-risk plaques gives the NIR and referring clinician increased confidence to treat lesions without severe stenosis but with high-risk plaques.

Pre-stent angio

Post-stent angio

•  Access – R distal radial artery
•  Sheath – Ballast 088  (alternative Penumbra Neuron Max 088, Fubuki 6F)
•  Distal protection device - Emboshield Nav 6 (alternative Filterwire Ez, Spider Fx)
•  Stent – X. Act 7-9 mm x 40 mm and Carotid Wallstent 7 x 50 mm (alternative Precise Pro RX, Protégé Rx)

Follow-up

•  Follow-up at 8 months after carotid stenting.
•  Stent remains patented.
•  No further symptoms.