Red Herrings and Hidden Perils

A 76-year-old male presented with a history of multiple cerebrovascular accidents (CVAs). The patient had undergone carotid angiography 2 years prior to presentation and was described as having a 50% right internal carotid stenosis. He was started on 325mg of acetylsalicylic acid (ASA) daily and 75mg of clopidogrel daily, as well as aggressive risk factor management.

Two weeks prior to presentation, he was readmitted for another left side transient ischemic attack (TIA) while on clopidogrel (Plavix^®, Bristol-Myers Squibb, New York, New York). Carotid duplex scan suggested the right internal carotid stenosis was 70% or greater and the left was unremarkable. He has no residual neurological deficit. His risk factors for vascular disease include hypertension and hyperlipidemia. Previous cardiac work-ups, including echocardiogram and nuclear stress testing, were negative.

With the worsening right carotid stenosis and a new TIA event while on ASA and clopidogrel, a carotid angiogram was scheduled. His pre-cath physical was remarkable for a soft right carotid bruit, with normal heart sounds.

Carotid angiography was performed. During the procedure, there was significant difficulty navigating a wire and catheters through the abdominal aorta. A long Cook sheath (Cook Medical, Bloomington, Indiana) was advanced, followed by a 5 Fr pigtail catheter (Cordis Corporation, Warren, New Jersey). Arch aortography was performed in a 40° left anterior oblique projection. This showed normal great vessel anatomy and mild plaque in the aortic arch. A wire exchange was made for a 5 Fr Vtech catheter (Cordis Corporation). This catheter was engaged in the right carotid artery. At this time, prior to any injection, the patient became unresponsive and could no longer verbalize. He could not move his right arm or leg. The case was aborted. CT scan/MRI showed a large left middle cerebral artery stroke. CT scan of the abdomen showed an 8.5 cm infrarenal abdominal aortic aneurysm. A transesophageal echocardiogram (TEE) was performed and demonstrated a large thrombus load in the ascending aorta and arch. The patient was anticoagulated and treated with supportive care, and ultimately, taken to an acute rehab facility.

This case demonstrates several issues of a right carotid stenosis that may or may not have contributed to this gentleman’s symptoms (The Red Herring). In addition, the large abdominal aortic aneurysm and the large thrombus load in the ascending aorta were completely unexpected (The Hidden Perils). The thrombus in the arch more than likely explains the recurrent TIA/middle cerebral artery events while on ASA/clopidogrel. It certainly makes one wonder if more thorough noninvasive screening such as TEE and abdominal ultrasound should be stressed prior to invasive testing to avoid such hidden perils. We find ourselves taking such complications for granted as they occur so infrequently, yet when they do occur, they have devastating effects on the lives of our patients.

We will be discussing clinical issues like the one presented at "Cardiovascular Tips for the Practitioner: Optimizing Management Techniques and Treatment" at the Wynn/Encore Hotel on September 9–10, in Las Vegas. For more information, contact Laurel Steigerwald at lsteigerwald@promedicacme.com [1]. We will be hearing from world leaders in the fields of myocardial infarction, arrhythmia care, and new interventional techniques to treat impotence and hypertension. In addition, for the first time in conjunction with the Society for Cardiovascular Angiography and Interventions (SCAI), we will be offering the SCAI Transradial Interventional Course on September 11. Join us at this unique and exciting interventional meeting. For more information, check out promedicacme.com/meeting/Cardiovascular-Tips-for-the-Practitioner-71.html.