Author + information
- Mu-Yang Hsieh1
Patient initials or identifier number
Relevant clinical history and physical exam
A 79-year-old man presented with acute ischemic stroke and received systemic thrombolysis immediately at the emergency department. He had a sudden onset of left drooling with left limbs weakness during eating at 13:00 on 2016/09/11. Left face and limbs numbness were reported. There was no consciousness change, no limbs twitching, no easily choking, and no double vision. According to the patient and his wife, he does not have a history of stroke, peptic ulcer, or an cardiovascular disease.
Relevant test results prior to catheterization
Carotid Duplex revealed 1. Critical stenosis of right ICA (diameter stenosis of 93%) and right CCA with hypo-perfusion of right hemisphere 2. Critical stenosis of right proximal VA 3. Focal stenosis (diameter stenosis 77%) of left proximal ICA.
CT angiography and brain perfusion imaging confirmed bilateral ICA stenosis, Rt VA occlusion, and Lt VA ostium stenosis. There was significant ischemia in Rt cerebral hemisphere while remaining viable.
Relevant catheterization findings
Rt ICA: severe critical stenosis, with String sign.
Lt ICA: severe stenosis.
Rt VA: occluded, collaterals from external carotid artery branches.
Lt VA: ostium stenosis.
Staged procedure 1: Lt VA and Lt ICA, reasoning: to improve whole brain perfusion and to allow the use of proximal occlusive protection device during Rt ICA intervention.
* RFA puncture, 6Fr long sheath (90 cm).
* Distal filter protection to stenting Lt VA and Lt ICA (Spider EV3, 7 mm).
* Lt VA: coronary stent, Omega 4.5 x 12 mm. Post-dilate with 5.0 NC Quantum balloon to 18 ATM.
* Lt ICA: protection distal filter, stenting with closed cell Nitinol stent (WallStent, 9 x 40 mm). Post-dilate with 4 mm Sterling balloon.
Staged procedure 2: Rt ICA, reasoning: definitive treatment to improve Rt hemisphere perfusion. Use double protection to prevention distal embolization.
* RFA puncture placed a 9Fr sheath.
* Double protection strategy employed.
* Proximal occlusive protection device (MoMa) to Rt ECA-CCA.
* Inflate the ECA and CCA balloons.
* Wiring through Rt ICA critical stenosis: Fielder FC, Sion, BMW-U2. Finally, succeed with UB3/Finecross.
* Pre-dilate with 2.0 x 20 coronary balloon (Sapphire).
* Placed distal filter wire (Spider EV3, 7 mm)
* Stenting with 9 x 40 mm WallStent. Complicated with stent migration.
* Re-attempt to stent with 6 Fr shuttle system, finally stented with WallStent 9 x 30 mm.
* Final results good perfusion. No distal embolization.
For patients with severe atherosclerotic disease in bilateral carotid and vertebral arteries, the intervention strategy is important to improve success and avoid complication. For critical stenosis combined string sign, using double protection and careful planning may lead to a favorable outcome.