Dr performed a 4 vessel carotid angiogram and a right carotid stent:
Operation/Procedure:
1. Four-vessel carotid angiogram.
2. Right internal carotid artery angioplasty and stenting using 8 x 6
x 30 mm Xact self-expanding stent.
Indication: Severe right carotid artery stenosis on Doppler study.
The ptient is at hogh risk for surgery.
Description of Operation/Procedure: After informed written consent was obained from the patient, the patient was brought to the cardiac catheterization suite in nonsedated state. The right groin was prepped and draped according to standard sterile manner.
A 6-French sheath was introduced through the right femoral artery using modified Seldinger technique. A 6-French pigtail catheter was used for aortogram at the aorotic arch level. After that, JR4 diagnostic right brachiocephalic artery. A 5-French VTEC catheter was used for left common caoritd artery angiography.
Findings:
1. Aortic arch is type B, origin of all greater vessels are within normal limits wthout any significant sotial stenosis.
2. Left subclavian artery appeared to be widely patent proximally.
3. Large vertebeal artery is originating from the proximal segment,
vessel is large withi antegrade flow without any significant disease.
After the origin of the brachiocephalic artery, the subclavian artery shows significant stenosis with probably at least 85% may be 90% narrowing, relatively short segment.
Beyond that, the vessel is relatively normal again.
4. Right brachiocephalic artery is large caliber vessel, appeared
free of any significant stenosis. Vertebral artery on the right side is moderate caliber with antegrade flow.
5. Right common carotid artery is large caliber vessell. There is
about 40% to 50% ostial narrowing. Also, there is an area of moderate
disease in the proximal part of the vessel beyond this area, the
vessel is good size again with no significant stenosis until the bifurcation. After that, the vessel bifurcates to internal and external carotid arteries. The external carotid artery shows a critical ostial narrowing of about 95% to 98%. The ostium of the right internal carotid artery is widely patent. About 15 to 20 mm after the origin of the vessel, there is a high-grade stenosis in the internal carotid artery with at least 85% to 90% focal narrowing. Beyond this area, the vessel is large caliber and appeared free of any significant stenosis.
6. Left common carotid artery is widely patent all the way to the bifurcation. After that bifurcation, there is moderate plaque and mild calcification about 50% or so narrowing overall the seen, does not appear to be hemodynamically significant, some views suggest maybe the stenosis is a little bit more and somewhat eccentric, but the majority of the views showed this area to be moderate. External carotid artery shows some mile to moderate ostial disease about 40% or so.
After careful review of the angiogram, we decided the knowing that the
patient is at high righ for surgery, we decided to proceed with
intervention on the right internal carotid artery. At this point, we
used the VTEC catheter ________ brachiocephalic artery. We advanced a long TAD wire to the external carotid artery. After that, we advanced 6-French shuttle sheath to the mid right common carotid artery. Large Emboshield filter was advanced relatively easily across the stenotic segment and the filter was deployed cephalad to the lesion.
After that, we used 4.0 x 15 mm balloon to perform, one single dilation.
After that, we advanced 8 x 6 x 30 mm Xact self-expanding stent. Stent was
deployed covering the lesion fully. The proximal part of the stent was deployed in the proximal internal carotid artery. There was no need to cover the bifurcation. After that, we used 5.0 x 15 mm balloon to perform post dilation at 12 atmospheres. Full expansion of the stent took place. Brisk flow was seen after that. The filter was then retrieved without any events. Final angiogram showed excellent results and complete resolution of the stenosis from 90% to less than 10%.
Selective angiogram of the right femoral artery was performed followed
by deployment of ExoSeal closure device in the right common femoral artery with good hemostatis.