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Interventional CV Rounds

Coordinator: Dr. Hugo Londero
Moderator: Dr. Raúl Bretal

Case number 2: Patient with a Carotid Angioplasty
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Opinion of Dr. Mark Whooley
Opinion of Dr. Michel Henry
Case Resolution

Opinion of Dr. Mark Whooley ,
Chairman, Pittsburgh Vascular Institute, Pittsburgh, Pennsylvania, USA

A review of the angiogram demonstrates the right internal carotid to be completely occluded with the external being patent and providing some degree of minimal collateralization to the intracranial segment of the right internal carotid. The right vertebral is widely patent but demonstrating minimal atherosclerotic changes and also minimal atherosclerotic changes noted in the basilar, but no significant occlusive disease that would warrant intervention on the basilar. The right vertebral, being the dominant vertebral, also is responsible with flow to the basilar and subsequently collateralization to the right cerebral hemisphere considering the right internal carotid is occluded.

The left internal carotid demonstrates a 70-75% segmental narrowing. In the event the patient is symptomatic, I would recommend stenting, considering this vessel is responsible for both hemispheres. Even in the absence of symptoms, I may consider stenting this patient, again, because of the importance of providing both hemispheres with circulation. The stent for this particular application would either the AccuLink tapered, and I would think a 6-8 would be an appropriate stent, 30 mm long. Optionally, a SMART stent, a 20mm by 7 mm would also be satisfactory. Both stents might extend across the bifurcation which would not be a technical problem.

In addition, the ostial lesion at the left vertebral is quite significant and approaches at least 85% short segmental narrowing. With the left vertebral, I would stent at the same time with the multipurpose guide, and position an 8 mm AVE or a similarly short MultiLink (duet stent) and expand that stent to 4 mm. Both procedures could be done in a single stage. The 9 French guide would have been used for either the SMART on the AccuLink and that same guide would function satisfactorily for the vertebral lesion. The wire that I would be an .014 Ironman in both situations.

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Opinion for Michel Henry
Co-Director Interventional Cardiology Unit, Polyclinique Essey-les-Nancy, France

1.- Total occlusion of the Right Internal Carotid Artery
2.- A concern of intracranial stenosis at the upper part of the right vertebral artery (sent video images not clear)
3.- Tight eccentric ulcerated stenosis of the left internal carotid artery above the bifurcation.
4.-Severe ostial left vertebral artery stenosis.

Proposed Treatment

Based on patients symptoms and above angiographic we propose the following:

1. Angioplasty and stenting of the left vertebral artery.
2. Angioplasty and stenting of the left internal carotid artery under cerebral protection.


We think that of the left vertebral artery lesion is quite severe to justify intervention.

In this specific case vertebral dilatation will increase the cerebral blood flow making brain ischaemia, during protection balloon inflation more tolerable. Filter protection devices during carotid angioplasty is another option.

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Case Resolution

Dr. Oscar Mendiz

We have thought that this is a patient who requires a revascularization procedure to face left internal carotid artery and left vertebral ostium narrowing. These kind of patients were excluded of NASCET study due to having contralateral occlusion which increased surgical risk; but these patients have been usually included in all carotid stent assisted angioplasty registries with good proved results; so we considered that these patients could be benefited with a carotid stent angioplasty and vertebral artery stent angioplasty.

The other point was to decide about cerebral protection device utility in this case and if the answer was yes; which one, owing to this patient has contralateral occlusion that can decrease left carotid transient occlusion with occlusive balloon protection device.

We decided to use balloon protection device (PercuSurge) due to the availability of it under a clinical study (CAFÉ Study), in a staged or continuous procedure according to patient tolerance, but trying to do a short simple procedure a primary stent was scheduled.

It is important to point out that the collateral to the right brain hemisphere was supplied mainly by right vertebral artery, so we decide to perform carotid angioplasty and later, in a staged procedure, the vertebral artery. Using an 8 French multipurpose guiding catheter by femoral approach, the PercuSurge GuardWire was distally advanced through the lesion, and distal balloon was insuflated. Immediately premounted over the wire 5.0 mm. balloon with a previously crimped stent (J&J. Palmaz P154) which was previously left just bellow the lesion was advanced up to there and quickly inflated at 12 ATM. and deflated in 10 seconds and withdrawn. (Figure N°3)

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Fig. 3

After removing the balloon catheter, two aspirations with the Export catheter were done followed by distal protection balloon deflation; with an acceptable final angiographic result.

All the procedure was well tolerated and did not occur any complication and the patient was discharged the following day under Aspirin and Clopidogrel treatment.

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