A 74-year-old male
patient was referred to our clinic for evaluation for CAS. Doppler
ultrasonography (US) and magnetic resonance angiography (MRA) showed ulcerated,
calcified and eccentric plaque causing 50%-60% stenosis in the proximal part of
the left internal carotid artery (ICA). The patient had a history of right
transient hemiparesis, which had occurred three months previously. He was on
medicine for hypertension and Type 2 diabetes mellitus. Daily, 100 mg ofacetylsalicylic acid (Aspirin; Bayer healthcare, Germany) and 75 mg of
clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals, NY, USA) were
prescribed and the CAS was planned for approximately 10 days later. Before the
procedure, Aspirin and Plavix sensitivity were tested with Verify Now
(Accumetrics, San Diego, CA, USA). The patient was sensitive enough and one day
later, the procedure was accomplished.
Before the procedure,
a diffusion-weighted MR was performed to detect any new ischemic lesion caused
by the CAS procedure. Diagnostic angiograms obtained under local anesthesia
showed 50% stenosis consistent with the Doppler US and MRA. Heparin
(5000 IU) was administered intravenously (IV) and then the left common carotid
artery was catheterized with a long shuttle sheath (Cook Inc., Bloomington, IN,
USA) with the assistance of an exchange, hydrophilic 0.035-inch guide wire; a
distal protection filter (Emboshield NAV6, Abbott, Redwood City, CA, USA) was
placed inside the ICA, 4-5 cm away from the stenosis. A hybrid tapered carotid
stent, Cristallo Ideale 9-6×30 mm in size (Invatec, Medtronic, and Santa Rosa,
CA, USA) was implanted and a 4×20 mm monorail balloon was used for dilation
after stent implantation. A second, identical carotid stent, the same size as
the first stent, was deployed inside the second stent for covering and
preventing the plaque protrusion inside the first stent. And then, a 5×20 mm
monorail balloon dilation was applied and the opening was optimal without any
residual stenosis.Read more.....
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