Outcomes of angioplasty and stenting at the common carotid origin

Acute Ischemic Stroke due to Common Carotid Ostial Disease with Tandem Intracranial Occlusions Treated with Thrombectomy and Staged Retrograde Stenting

Background

Acute ischemic stroke due to tandem occlusive lesions of the anterior circulation involves an intracranial large vessel occlusion as well as a concurrent occlusion or high-grade stenosis of the proximal carotid system. The vast majority of proximal lesions in tandem occlusive cases involve the extracranial internal carotid artery, although the lesion can theoretically exist anywhere along the carotid artery pathway, including the common carotid ostium.

Summary

To the best of our knowledge, only 1 report describes common carotid artery ostial lesions in the setting of acute ischemic stroke due to tandem occlusions, in which the authors describe an anterograde treatment paradigm. We present the first 2 cases of acute ischemic stroke secondary to common carotid ostial disease with tandem intracranial occlusion, treated with intracranial thrombectomy followed by subsequent staged balloon-mounted stenting of the common carotid ostium. We review the pathophysiology of tandem occlusions, the controversy surrounding treatment techniques, and various approaches used in the treatment of ostial occlusive lesions.

Key Message

In certain situations where acute carotid stenting is not safe or technically possible, immediate intracranial thrombectomy with a subsequent staged balloon-mounted stenting of the ostial lesion may be a reasonable and safe option.

Traumatic Penetrating Neck Injury with Right Common Carotid Artery Dissection and Stenosis Effectively Managed with Stenting: A Case Report and Review of the Literature

Introduction

Penetrating neck injuries (PNI) are common and associated with arterial and other neuronal injuries. Although many authors have written on penetrating and blunt carotid artery injuries as a result of PNI or traumatic neck injuries, no one has reported a case or case series on PNI that resulted in blunt carotid dissection and stenosis.

Case Presentation

We present a case of 40-year-old building and construction male worker who slipped and fell on an iron rod that resulted in penetrating wound on the right side of the anterior neck a week prior to presenting at our facility. He pulled out the iron rod immediately. Computer tomography angiography (CTA) done revealed C2-C4 transverse process fractures on the right side and a fracture at the right lamina of C3 and right common carotid artery dissection with stenosis. He was successfully treated with stenting via endovascular approach.

Conclusions

We adopt the view that patient should never pull out objects that result in PNI because of complex neurovascular architecture of the neck. The mortality rate of our patient will have doubled if the iron rode penetrated the common carotid artery. The gold standard treatment option for carotid artery dissection and stenosis is endovascular approaches.

Blunt traumatic transection of the right common carotid artery

Background

Carotid injuries are infrequent following blunt traumatic injury but can have potentially devastating neurologic consequences. We present a case of a 31-year-old male with right common carotid transection after blunt trauma to the neck.

Case report

A 31-year-old male with no notable medical history presented as a trauma level one activation after riding his bicycle into an open car door causing a Zone II laceration of his right anterior neck. The patient was hemodynamically normal, had an intact airway and had no neurologic deficits on evaluation in the trauma bay. He underwent a computed tomography angiogram of his neck which revealed a focal dissection of the right common carotid artery causing a 70%–80% luminal narrowing suspicious for a grade II injury. The patient was taken to the operating room for exploration of his neck laceration. He was found to have a grade V injury with complete transection of the right common carotid artery through the intima and media with intact adventitia. The arterial injury was repaired with polytetrafluoroethylene interposition graft. Perioperatively, the patient was started on dual antiplatelet therapy. He recovered uneventfully without neurologic deficits.

Conclusion

Complete transection of the common carotid artery following blunt trauma is rarely reported. Based on a review of the literature regarding blunt carotid injuries, it is reasonable to repair such injuries with prosthetic graft followed by either systemic anticoagulation or dual antiplatelet therapy.

Management of carotid artery trauma

With increased awareness and liberal screening of trauma patients with identified risk factors, recent case series demonstrate improved early diagnosis of carotid artery trauma before they become problematio. There remains a need for unified screening criteria for both intracranial and extracranial carotid trauma. In the absence of contraindications, antithrombotic agents should be considered in blunt carotid artery injuries, as there is a significant risk of progression of vessel injury with observation alone. Despite CTA being used as a common screening modality, it appears to lack sufficient sensitivity. DSA remains to be the gold standard in screening. Endovascular techniques are becoming more widely accepted as the primary surgical modality in the treatment of blunt extracranial carotid injuries and penetrating/blunt intracranial carotid lessions. Nonetheless, open surgical approaches are still needed for the treatment of penetrating extracranial carotid injuries and in patients with unfavorable lesions for endovascular intervention.

Acute carotid artery dissection treated with stenting and hematoma aspiration guided by ultrasonography

We report the successful treatment of dissection with stenosis of the carotid artery by stenting and aspiration of hematoma. A male patient, presenting with acute blurred vision and weakness and numbness of the right side of his body, was diagnosed with common carotid artery (CCA) dissection and severe stenosis of the internal carotid artery and CCA by digital subtraction arteriography and color Doppler ultrasonography (CDU). Two stents were separately implanted into the left internal carotid artery and CCA to restore blood flow and seal the opening of the dissection. The hematoma inside the CCA dissection was transcutaneously aspirated under CDU guidance after thrombolysis with tissue plasminogen activator. Three days after the operation, the dissection was still sealed. The patient was discharged 1 week later without any signs or symptoms. Follow-up examination at 70 days confirmed complete healing of the CCA dissection. Transcutaneous intradissection hematoma aspiration with CDU guidance may be applicable in treating arterial dissection, especially when conservative treatments cannot be expected to improve severe flow disturbances.