Author + information
- Shih-Wei Meng1
Patient initials or identifier number
Relevant clinical history and physical exam
A 59-year-old man had DM, hypertension and CKD admitted for cognitive function decline. MRI disclosed recent infarction at left corpus callosum and probable sub acute episode in left MCA territory. Severe left ICA stenosis found also. New stroke developed during admission at left cerebrum followed by NSTEMI and was treated with medical therapy. However, recurrent NSTEMI with lung edema occurred one month later with right side weakness again. We did interventions to solve problems this time.
Relevant test results prior to catheterization
1. Severe atherosclerotic change over left ICA (87%, PSV 636 cm/s).
2. Mild to moderate atherosclerotic change at bilateral CCA, carotid bifurcations and right ICA.
3. Lt VA hypoplasia and stenosis with inadequate total VA flow.
- Relevant catheterization findings
1. 6Fr diagnostic catheter with Terumo Stiff Glidewire 260 cm to Lt ECA then change to 9Fr. sheath
2. Using 260 cm Stiff Terumo Glidewire, insert 9Fr MoMa to Lt ECA-CCA
3. Generous flushing and prepared distal protection device (Spider 7 mm)
4. Inflate ECA balloon (till balloon shape became square) then CCA balloon (till balloon shape became square)
5. Wiring into Lt ICA with Run through
6. Insert Spider and deploy filter at distal cervical Lt ICA (7 mm)
7. Deploy Wall Stent 8 x 29 mm to cover both Lt ICA stenosis and distal ICA tandem lesion
8. Post-dilate with Sterling 4 mm balloon 8 ATM
9. Withdrawal total 100 ml from aspirate port of MoMa
10. Deflate ECA and CCA balloon of MoMa sequentially
11. Retrieve the Spider filter with retrieval device
12. Final result and flow to cerebrum good
13. Post procedure BP 64/70 mmHg improved to 110/70 mmHg with N/S 500 ml and Levophed 30 ml/hour
14. POBAS with Orsiro 2.5 x 30 at distal LAD then 3.5 x 22 at proximal LAD
15. POBA to OM1 and close the whole procedure
According to prior randomized trials, carotid artery stenting with embolic protection device is an alternative equivalent to carotid end arterectomy in-patient having average or high risk of perioperative cardiac events. Recent myocardial infarction definitely poses significant surgical risk and restrain the usefulness of surgical endarterectomy. The use of both proximal and distal protection device may offer further benefits in minimizing distal embolic events. Further, under adequate, even mechanical support of hemodynamics, it is possible to perform revascularization of both carotid and coronary system subsequently to treat such complicated patient having both problems simultaneously.