Cath Lab Digest

Authors: Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, Hursh Naik, MD, Mark Boulware, MD

A 69-year-old male patient presented with asymptomatic carotid artery stenosis. The patient is considered high-risk because of non-revascularizable coronary disease and bilateral carotid disease. He had undergone previous left carotid endarterectomy and had a new right internal carotid artery stenosis by both carotid Doppler and CTA of 90%. The patient was enrolled in the Abbott CHOICE high-risk protocol. The patient had the procedure done via the right groin with a VTK catheter (Cook Medical, Bloomington, Indiana) placed through a 6 Fr shuttle (Cook Medical). The Emboshield (Abbott, Abbott Park, Illinois) was passed and the lesion was predilated with a Viatrak 4.0 balloon (Abbott). After predilation, the Exact 40 mm stent (Abbott) could not be passed. We went in with a Viatrak 5.0 balloon and inflated several times, but still could not pass the stent. Following this, we used a 3.5 x 20 mm AngioScope balloon (AngioScore, Fremont, California), which clearly showed the indentation with inflation and resolved. Following this, the 8/6 40mm Exact stent was passed easily. With deployment of the stent, we post-dilated with the Viatrak 5.0 balloon and the stent appeared to be fully deployed. We performed an angiogram with the filter still in place, which revealed delayed filling. Because of this, we passed a Pronto catheter (Vascular Solutions, Minneapolis, Minnesota) and performed multiple suctions. In spite of multiple aspirations, even after 4 suctions, there was still embolic material present (Figure 1). However, the thrombotic material finally cleared after 6 aspirations and an angiogram confirmed that the TIMI delayed filling had resolved and the filter was removed with excellent angiographic result.

This case showed 2 problems. The length of the lesion made it clear that adequate predilation was necessary. In this case with the non-approved application of the AngioScope balloon to predilate, it was possible for us to place the stent. Secondly, a delayed filling after filter placement showed the necessity of suction after deployment of the stent in this case was vital. The amount of material suggested that this was a lesion with a large thromboembolic load.

Figure 1. Carotid angiogram prior to intervention.

Figure 2. Carotid angiogram following placement of the stent revealing delayed filling.

Figure 3. Carotid angiogram revealing carotid delayed filling.

Figure 4. Final angiographic result.

Figure 5. The filter aspiration revealed extensive thromboembolic material.