Author + information
- Received April 10, 2017
- Accepted April 28, 2017
- Published online June 28, 2017.
- Nagaraja Moorthy, DM∗ (, )
- Rangaraj Ramalingam, DM,
- Subramanyam K. Setty, DM,
- Shivanand S. Patil, DM and
- Manjunath C. Nanjappa, DM
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
- ↵∗Address for correspondence:
Dr. Nagaraja Moorthy, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India 560069.
A 42-year-old woman was admitted with history of recurrent syncope of more than 10 to 15 episodes per day for more than 3 months that worsened over 1 month. She was diagnosed to have aortoarteritis type I 3 years before when angiography showed total occlusion of bilateral subclavian (Figures 1A and 1B, Online Videos 1A and 1B), bilateral vertebral, and left common carotid arteries (Figure 1C, Online Video 1C). The right common carotid artery had diffuse 70% lesion. Her coronary arteries, renal arteries, and aorta were normal. As she was asymptomatic and considering discouraging results of percutaneous interventions in aortoarteritis she was advised medical follow-up and treated with immunosuppresion. Just before repeat computed tomography (CT) angiography of neck vessels she had acute left faciobrachial monoparesis. All 4 neck vessels were occluded (Figures 1D and 1E) and the sole brain was supplied by tiny collaterals. CT of the brain showed right frontotemporoparietal acute infarct (Figure 1F). In view of the urgency of revascularization and risks involved in surgery it was decided to perform urgent percutaneous angioplasty. Because the right common carotid artery was the latest to block it was decided to open it, as success rate could be better when compared with other 3 neck vessels. The right carotid artery was hooked with 6-F shuttle sheath. The lesion was crossed with 0.014-inch Pilot 150 wire (Abbott Vascular, Santa Clara, California) (Figure 2A, Online Video 2A). However, because there was no support over this wire, it was exchanged to a 0.035” exchange wire (Medtronic, Inc., Minneapolis, Minnesota) to place at the distal end of the wire in the external carotid artery (Figure 2B, Online Video 2B). In view of recent stroke and to prevent embolism, hardware manipulation was minimized and it was decided to perform direct stenting without pre-dilatation. A 6 mm × 100 mm Complete SE self-expanding stent (Medtronic, Minneapolis, Minnesota) distal edge was meticulously placed just at the bifurcation of the common carotid artery and deployed. Post-stenting underexpansion of the stent was noted (Figure 2C, Online Video 2C). Post-dilatation was done using a 7 mm × 20 mm NuMed (B. Braun Medical Inc., Hokinton, New York) balloon catheter. The final result showed a well-expanded stent with significantly improved perfusion to the brain (Figure 2D, Online Video 2D). No procedure-related complications were noted and she had complete relief from syncope. The repeat carotid Doppler at 6 months follow-up showed the patent stent (Figure 2E, Online Video 2E) and she remained asymptomatic.
Chronic total occlusions of neck vessels are not uncommon in aortoarteritis. Chronic total occlusions of all neck vessels presenting as recurrent syncope are very rare. Though percutaneous stenting of atherosclerotic total occlusion of the carotid artery is considered as contraindication, in rare conditions such as aortoarteritis percutaneous stenting could be considered as a safe and effective alternative to surgery.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 10, 2017.
- Accepted April 28, 2017.
- 2017 American College of Cardiology Foundation