Left Common Carotid Stenting post-Radiotherapy

Clinical Data:

Man, 62 years, past smoking, dyslipidemia, HTN

1986: oropharyngeal cancer

Positive treadmill stress test

No neurological symptoms but rapid worsening of a severe left common carotid artery

Previous imaging:

CT scan: confirms the severity of the lesion, witch seems to be limited to the left common carotid artery with no extension beyond to the bifurcation

Reasons for carotid revascularization:

Fast worsening of a severe stenosis

Reasons for CAS:

High surgical risk (post radiotherapy neck, CAD)

Learning objectives:

• How to treat post radiotherapy lesions?
• When and how to use distal protective devices in CAS?
• How could 3D Rotational Angiography be useful in carotid artery stenosis evaluation and stenting procedures?
• Is there a role for IVUS?
• What types of stents to use in CAS procedures, and what is the rational of this choice?
• How to follow patients after CAS for post Rx lesions?

Procedural steps:

1. Access:

• Right femoral access, 8F, 23 cm BRITE TIP ® sheath, Cordis
• Canulation of the BCT then the Right Common Carotid Artery with a Hockey Stick 8F, 100 cm Guiding Catheter (Cordis), advanced upon an 0.035" Radiofocus Terumo angled stiff Guide Wire-M, 260 cm (TERUMO)

2. Evaluation of the lesion

• 3D rotational angiogram
• Embolic protection system 3,5 – 5,5 mm, 190 cm, FiterWire, EZ, Boston Scientific
• Rx Digital IVUS Catheter, 0,014’’ – 150 cm, Eagle Eye Platinium, Volcano

3. Stent placement and postdilation:

• ADAPT Monorail Carotid Stent System, 4 – 9 x 21 mm, Boston Scientific Corporation
• Balloon Dilation Catheter, 7 x 20 mm, Ultra-soft SV, Boston Scientific Corporation

4. Result control:

• Rx Digital IVUS Catheter, 0,014’’ – 150 cm, Eagle Eye Platinium, Volcano
• 3D Rotational Angiogram