Teaching Case

Restenosis after surgical revsion of a carotid stenosis of left internal carotid artery

The patient was admitted because of a sonographically proven restenosis of the left internal carotid artery. She had undergone bilateral carotid endarterectomy; her left side had been operated 9 months before but restenosis occurred 5 months after surgery. Her medical history included coronary and cardiac insufficiency, coronary stenting had been done a year before. Her neurological symptoms were mild with some nausea but no transitory ischemic attacks. Angiography via a transfemoral approach was performed detecting a high-grade restenosis of her left internal carotid artery 1.5 cm cranial to the carotid bifurcation (Fig. 1). The right side was free from restenosis. The vascular surgeon decided to send the patient for percutaneous treatment instead of surgery.

After retrograde puncture of the right femoral artery, selective catheterization of the left common carotid artery was performed using a 4 F headhunter 1 catheter. The catheter was selectively advanced into the external carotid artery and 260 cm long stiff Amplatz guidewire was introduced with its straight tip into the external carotid artery. Over the stiff wire a 90 cm long 7 F carotid sheath was advanced into the common carotid artery (Fig. 2a). After removing the guidewire, a 0.020 Schneider gold tip wire (BSIC) was advanced through the sheath over the stenotic segment. Keeping the guidewire in place, a 5 mm wide 20 mm long balloon catheter with a shaft of 120 cm was passed into the stenotic segment and dilatation was performed resulting in opening of the stenosis but with some irregularities at the former stenotic site (Fig. 2 b). Thus, a 6 mm 36 mm long self-expanding Wallstent was advanced into the internal carotid artery and delivered in such a way that its caudal end met the orifice of the internal carotid artery resulting in full opening of the lesion (Fig. 2 c and d) The patient was put on full heparinization for 72 hours and combined antiplatelet therapy was continued . The follow-up course was uneventful. Carotid stenting is a hot topic in interventional radiology. There is some dicussion whether it should be offered as a primary treatment instead of surgery. There are some risks of periprocedural TIA or stroke especially in atherosclerotic lesions. There are however two types of lesions which both surgeons and interventionalists agree on to be good candidates for percutaneous stent implantation: postsurgical strictures and postradiation stenosis. In both lesions, risk of TIA or stroke from plaque material is low because their surface is relaztively smooth, thus no protection device was used in the case presented. Long-term resutls of carotid stenting are not yet well established although single-center on larger patient cohorts exist