Author + information
- Tsung Yu Ko1
Patient initials or identifier number
Relevant clinical history and physical exam
A 76-year-old man with coronary artery disease, three vessels disease, received coronary stenting.
Hypertension. The patient suffered from dizziness for a long time, he received carotid duplex, the duplex revealed bilateral internal carotid artery severe stenosis. The patient did not have a history of stroke. His physical examination revealed bruits over bilateral carotid artery. His neurologic examination was normal no obvious neurologic deficit.
Relevant catheterization findings
The patient received percutaneous intervention via femoral assess, level III aortic arch was noted. It is difficult to engage Rt CCA and Lt CCA via femoral access.
1st Treat right subclavian artery stenosis
1. Puncture right brachial artery and set 7Fr sheath
2. Use Boston JR4 guiding catheter, stenting to right subclavian artery with Boston Express 7 x 19 mm stent
3. Post dilatation to subclavian artery stent with 8 x 20 mm balloon
1. Try to engage Right CCA with JR catheter and BL catheter with ST01 support but failed
2. Engage to right CCA proximal part with BL catheter, try to advance BL catheter to Right CCA distal part but failed.
3. Wiring to Right ECA with 0.018 wire (V-18), use 6 mm balloon anchoring at Right ECA, successful advance guiding catheter to Right CCA distal part
4. We choose spider embolic protection device, wiring to right ICA distal part with Gram Slam wire and use spider e mbolic protection device
5. Pre-dilatation to right ICA stenosis with 3.5 x 12 mm balloon up to 8A5″
6. Stenting to right ICA with CarotidWall stent 8 x 29 mm
7. Post dilatation to right ICA stent with 6mm balloon upto 12A5, acute stroke was noted presented with facial palsy and left side weakness
8. Retrieve embolic protection device, multiple emboli were noted
9. Cerebral angiography showed no hemorrhage nor large vessel occluded
10. Intervention closed, further CT study showed large vessel patency with multiple embolic event at right MCA territory.
1. Trans-brachial approach for ipsilateral carotid artery stenting is feasible for unfavorable type of aortic arch
2. Balloon anchoring at right external carotid artery is feasible for better engagement of guiding catheter during ipsilateral transbrachial approach for carotid artery stenting
3. Embolism protection with specific device or either multiple protection strategy for high risk patient is crucial.