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Stroke preventive bilateral carotid artery stenting before coronary bypass surgery
- Operator: Daniela Cerná, MD
Clinical Information

- Relevant clinical history and physical examination:
Patient was admitted for a coronary heart disease evaluation. His risk factors were smoking, hypertension, and dyslipidemia. He presented with chest pain, dyspnea and claudications. Physical examination was unremarkable except for a bilateral carotid and femoral artery bruit, and impalpable both the peripheral artery pulsations.

- Relevant test results prior to catheterization:
An exercise treadmill test showed significant ST depressions in all leads and presenting symptoms. A carotid duplex scan showed a 70% stenosis of a right internal carotid artery (RICA) as well as 80% stenosis of a left internal carotid artery (LICA) and advanced atherosclerotic changes of peripheral arteries. Transcranial doppler investigation showed no intracranial artery stenosis, but changes in blood flow parameters in accordance with carotid artery disease. Echocardiographic examination showed left ventricular hypertrophy with LV EF 55%.

- Relevant catheterization findings:
The coronary angiography showed significant diffuse atherosclerotic changes - tandem stenosis of left anterior descending artery (LAD), 70% ostial stenosis of left circumflex artery (LCx) and collateralized proximal occlusion of right coronary artery (RCA) (Figure 1, Figure 2, Figure 3, Figure 4). Carotid angiography revealed 75% ostial RICA stenosis (Figure 5) and 80% ostial LICA and 70% left external carotid artery stenosis (Figure 6). Furthermore, it was found advanced atherosclerotic changes in the both pelvic arteries (Figure 7, Figure 8).

Interventional Management
- Procedural step:
It was decided to treat the coronary heart disease surgically - patient was accepted for CABG. Because of high periprocedural risk of stroke and chronic nature of ischemic heart disease, it was possible postpone surgery for a month and provide bilateral carotid artery stenting (CAS). At first, CAS of RICA was performed using an Amplatz Right guiding catheter 8F (Boston Scientific, Natic, MA) and Filter Wire (Boston Scientific, Natic, MA) protection system (Figure 9). We implanted 6-9mm x 40mm Sinus stent (Optimed Medizinische Instrumente GmbH, Ettlingen, Germany) without predilation (Figure 10, Figure 11) and the stent was postdilated by 6mm x 20mm Ultrasoft baloon (Boston Scientific, Natic, MA) without residual stenosis (Figure 12, Figure 13). Then CAS of LICA was performed during the same procedure. Vitek catheter 5 Fr (Cook Inc., Bloomington, IN, USA) was used for diagnostic angiography and then using telescopic technique (and Vitek diagnostic catheter) was a long sheath (6 Fr) advanced into common carotid artery. Filter Wire (Boston Scientific, Natic, MA) embolic protection system was used as well. Subsequently 6-8mm x 40 mm Xact stent ( Abbott Lab., Abbott Park, IL, USA) was deployed directly without residual stenosis and didnt required postdilation (Figure 14, Figure 15).
After the postdilation of the first stent patient was hypotensive and the 500 ml infusion solution and dopamine 200mg was administered with effect, so procedure didnt have to be interrupted. Besides procedure was uneventful, without neurologic complications. Patient recovered well and successfully underwent CABG surgery after the one month of dual antiplatelet therapy with clopidogrel and aspirin. Peripheral artery disease is planed to be investigated in the next period.
Though there are still sufficient data missing, in certain cases (e.g. before CABG) it is possible proceed safely bilateral CAS during one operation.
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