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Carotid Artery Stenting in Rt.Internal Carotid Artery Stenosis
- Operator: Paul Hsien_Li Kao, MD
Clinical Information

- Relevant clinical history and physical exam:
The patient was 67 years old man. He was admitted to dizziness with transient ischemic attack. Now, there are no neurologic sequelae. He was evaluated with MR angiography with enhancement at another hospital. The MR angiography showed total occlusion of Lt.ICA with significant stenosis in Rt. ICA. And there were significant stenosis in both vertebral artery ostium. The US, carotid Doppler study at out hospital showed also, calcified plaque in Rt. carotid bulb and proximal ICA with about 75% stenosis and occlusion of left ICA. He received two times of PTA at Rt.SFA & EIA / Lf.SFA & CIA. He also received PCI at mLAD at several years ago.

- Relevant test results prior to catheterization:
The brain MR with angiography showed the severe stenosis Rt. ICA and total occlusion of Lt.ICA.

- Relevant angiography findings:
The pre-intervention angiography showed severe restenosis of Rt. ICA with total occlusion of Lt. ICA. Also, There was significant stenosis in both vertebral artery ostium. (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5)

Interventional Management

- Procedural step:
After Rt. femoral puncture, 8 Fr sheath was inserted. The 6 Fr JR 4 diagnositc catheter using 0.032 inch Terumo wire was engaged into Rt. ICA. And then, with 0.035 inch Terumo wire, the 8 Fr JR 4 guiding catheter was inserted. During procedure, we continuously infused some amount of nitrate due to high systolic blood pressure. We inserted cautiously distal embolic protection device (Filter Wire EZ) into the distal portion of Rt.ICA across the culprit lesion. (Figure 6) We deployed Carotid Wall self expandable stent 8.0 X 21 mm without predilation. (Figure 7) And we made a post-stent balloon dilatation with Ultra-soft 5.0 X 20mm up to 5.0 (6 atm). (Figure 8) During post-stent balloon dilation, there were bradycardia (slowest HR 48 beat/m) and hypotension (lowest BP 106/61 mmHg). All procedure was done uneventfully. Final angiogram showed some stenosis in just proximal part of stent but we decided to leave it due to reserved blood flow. (Figure 9, Figure 10)
- Thereafter, we inserted RINATO 0.014 inch guide wire into Lt.vertebral artery. (Figure 11) We deployed coronary BMS stent (Driver stent 4.5 X 15mm up to 4.85 (16 atm)) without predilation (Figure 12) and we used stent balloon up to 5.0 (20 atm) for post-stent balloon dilation. The final angiogram showed more improved cerebral perfusion. (Figure 13)

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