Ischemic stroke

CASE REPORT

Acute carotid stenting for treatment of stuttering
transient ischemic attacks after recent carotid
endarterectomy
Vinodh T Doss,1 Adam S Arthur,2 Clarence Watridge,2 Lucas Elijovich1,2
1

Department of Neurology,
University of Tennessee Health
Science Center, Memphis,
Tennessee, USA
2
Department of Neurosurgery,
Semmes-Murphey Clinic/
University of Tennessee,
Memphis, Tennessee, USA
Correspondence to
Dr L Elijovich, Department of
Neurosurgery, SemmesMurphey Clinic, 6325
Humphreys Blvd, Memphis,
TN 38120, USA;
lelijovich@semmes-murphey.
com

SUMMARY
Carotid endarterectomy (CEA) is the established standard
to treat occlusive extracranial atherosclerotic carotid
disease. Complications of CEA must be recognized and
dealt with efficiently due to the potentially catastrophic
neurologic sequelae. A 67-year-old African American
man was transferred from an outside hospital for an
acute stroke. He had initially presented with a small
right frontal subcortical infarct and had undergone a
right CEA 2 days prior to transfer. He had a fluctuating
examination with left-sided hemiplegia to slight
hemiparesis and inconsistent neglect. Head CT
demonstrated a watershed infarct of the right
hemisphere. CT angiography demonstrated high grade
stenosis at the distal aspect of the CEA anastomosis. He
was promptly taken for angiography and underwent
acute stenting of the right internal carotid artery. This
case demonstrates that carotid artery stenting is a safe
management strategy for the treatment of complications
associated with failed distal anastomosis during CEA.

BACKGROUND
Carotid endarterectomy (CEA) is the standard treatment for atherosclerotic occlusive extracranial carotid
disease.1 Known complications of CEA include cervical hematoma, cranial neuropathy, and rarely but
most importantly, acute symptomatic re-occlusion or
stenosis of the CEA site. The standard treatment for

To cite: Doss VT, Arthur AS,
Watridge C, et al. BMJ Case
Rep Published online:
[please include Day Month
Year] doi:10.1136/bcr-2013010766

this complication is emergent revision of the CEA.2 3
In this report we describe the successful endovascular
management of a case of acute symptomatic
re-stenosis of a CEA with emergent stenting. We
discuss the risks and benefits of this approach.

CASE PRESENTATION
A 67-year-old right-handed African American man
with a past medical history of hypertension and
hyperlipidemia was emergently transferred from an
outside hospital for fluctuating left-sided weakness
over a period of 2 h. He had undergone a CEA
2 days previously and was transferred to our hospital when his condition deteriorated. The presenting National Institutes of Health Stroke Scale
(NIHSS) score was 12 due to hemiplegia involving
the face, arm, and leg on the left, as well as sensory
deficits to light touch and hemi-neglect. CT of the
head and CT angiography at our institution demonstrated hypodensities in a watershed distribution of
the right hemisphere and a small intimal dissection
at the distal anastomosis in the cervical right
internal carotid artery with associated high grade
stenosis. There was no tandem intracranial embolus
identified (figure 1).

TREATMENT
Diagnostic angiography was performed with a 4 Fr
JB2 catheter. Right common carotid injection

Figure 1 (A) Non-contrast head CT demonstrates a watershed infarct in the territory of the right anterior circulation.
(B) Volume rendered three-dimensional reconstructed maximum intensity projection CT angiography of the neck
demonstrates a high grade stenosis distal to the right internal carotid bulb at the site of the carotid endarterectomy
anastomosis.

Doss VT, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010766

1

Ischemic stroke
confirmed high grade stenosis (76% using the NASCET (North
American Symptomatic Carotid Endarterectomy Trial) criteria)
with a dissection flap at the distal CEA anastomosis site without
intracranial occlusion (figure 2). Stenting was performed under
general anesthesia due to concerns regarding the patient’s ability
to maintain his airway while supine for a prolonged period due
to his acute neurologic deterioration. After intubation, the 4 Fr
sheath was exchanged for a 6 Fr Shuttle into the descending
aorta, and a 6 Fr slip-tip catheter was then advanced coaxially
through the Shuttle Sheath and used to select the right common
carotid artery over a 0.035 angled glidewire. The patient was
loaded with 600 mg of Plavix through a nasogastric tube and

the patient was heparinized to an activated clotting time of over
200.
A distal protection device (a 5 mm Cordis Angioguard emboli
capture system) was placed under roadmap guidance into the
distal cervical internal carotid artery. The carotid stent
(8 mm×30 mm 5 Fr Precise carotid stent) was carefully
deployed under fluoroscopy across the area of maximal stenosis.
Post stenting angiography demonstrated good apposition of the
stent against the arterial wall with correction of the previously
noted flap and no residual stenosis (figure 3).
The patient’s hospital course was otherwise uncomplicated. He
was discharged home 2 days after the procedure with slight facial

Figure 2 (A) Right common carotid digital subtraction angiography pre-stent placement. (A, B) Cervical anteroposterior (AP) and lateral images
demonstrate a patent carotid bulb with high grade stenosis (ie, measures 78% by NASCET (North American Symptomatic Carotid Endarterectomy
Trial) criteria) in the proximal internal carotid artery at the site of the carotid endarterectomy anastomosis. (C, D) Head AP and lateral images do not
demonstrate any intracranial tandem stenosis or occlusion.
2

Doss VT, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010766

Ischemic stroke

Figure 3 (A) Native lateral fluoroscopic image demonstrates a fully deployed stent within the right internal carotid artery (RICA). (B)
Anteroposterior (AP) and lateral right common carotid digital subtraction angiogram over the cervical region demonstrates relief of the stenosis
without any evidence of residual dissection flap. (C) AP and lateral right common carotid digital subtraction angiogram over the head does not
demonstrate any intracranial tandem stenosis or occlusion post stenting. (D, E) Diffusion weighted MRI of the brain post stenting with subacute
watershed infarct, as seen on the presenting non-contrast head CT (figure 1A) without a new acute infarct. Follow up ultrasound at six months
demonstrates long term patency of the carotid stent.
weakness and paresis of his left upper extremity. He had an
NIHSS score of 2 and a modified Rankin Scale score of 1. At the 6
month follow-up in the clinic, he was neurologically normal with
a modified Rankin Scale score of 0, and had returned to work.
Doss VT, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010766

DISCUSSION
Acute carotid artery stenting (CAS) after CEA has been previously described in a series of mostly asymptomatic patients. The
majority of symptomatic patients were found to have thrombus
3

Ischemic stroke
at the CEA site while only one was similar to our patient with a
flow limiting intimal flap/dissection at the distal CEA anastomosis
site.4 In most cases, CAS is considered in cases of chronic re-stenosis after a CEA. In several studies, CAS is preferred compared to
re-operation as complication rates are similar to CEA.5 In these
delayed cases of restenosis, the presence of scar tissue and the
potential need for an interposition graft to permit closure of the
arterotomy are the technical aspects of redo CEA that can
increase the risk of the procedure and make CAS a suitable alternative. Additionally, previous CEA is an established high-risk criterion that has been demonstrated to favor treatment with CAS.6
In traumatic or spontaneous cervical arterial dissection,
medical management is often the first line therapy because spontaneous healing is common over first 3-to-6 months, and stenosis may resolve in up to 90% of cases.7 8 Endovascular
treatment is reserved for patients with recurrent symptoms on
medical management or those with symptomatic hemodynamic
failure on presentation.
In our patient, the treatment was emergent and the decision
to treat was based on the hemodynamic compromise and new
symptoms.9 Furthermore, the intimal flap at the anastomotic
site would likely not have had the benign natural history as the
majority of spontaneous or traumatic dissections. This was a
technical problem that would not have improved with anticoagulation and would need to be repaired regardless of the symptomatic status. In the past, we have treated these patients with
reoperation and often have found that this complication can be
either treated or avoided altogether through the usage of circumferential, vertically oriented tack-up sutures using 6-0
prolene at the site where the distal plaque is fractured from the
intima.10 11 The decision on open versus endovascular treatment in this case was both technical and practical. We felt,
based on angiography, that the lesion could be safely treated
with CAS, and most importantly that an endovascular strategy
would be most efficient in limiting total ischemic time.
Alternatively, in cases of acute thrombosis at the CEA site reoperation and thrombectomy have been the standard treatment.
However, the new generation of endovascular embolectomy
devices may present an alternative in some patients who may
not tolerate re-operation and/or have occlusion documented
after exit from the operating room.
There were several factors that made CAS a suitable treatment
option. We were able to pass a distal protection device without
pre-dilation, thus mitigating the risk of embolic complications
and avoiding possible trauma to a vulnerable recent surgical
anastomosis site. The high-risk of procedural stroke (i.e., CEA
or CAS) in this situation highlights the unique advantage of
endovascular treatment as any tandem intracranial occlusion
could be treated at the same setting, thus reducing overall ischemic time. Important considerations prior to stenting include the

obligatory use of dual anti-platelets in the setting of recent
surgery and ischemic stroke.
In conclusion, CAS may be considered a safe alternative to
redo CEA for acute occlusion or stenosis after acute failure of
CEA in properly selected patients.

Learning points
▸ Carotid endarterectomy (CEA) is the standard treatment of
atherosclerotic occlusive extracranial carotid disease.
▸ One problematic complication of CEA is acute symptomatic
re-occlusion or stenosis of the CEA site.
▸ Symptomatic acute re-stenosis following CEA can be treated
successfully with emergent carotid artery stenting in selected
cases.

Contributors ASA and LE provided the conception and design. ASA, CW, and LE
performed the analysis and interpretation of the data. VTD and LE drafted the
manuscript. All authors revised the manuscript critically for important intellectual
content, and ASA and LE provided final approval of the version to be published.
Competing interests ASA has served as a consultant for Covidien, Johnson and
Johnson, Siemens, Stryker, and Terumo, and has received or has grants pending
from Siemens and Terumo.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1
2
3
4

5

6
7
8
9
10
11

Ferguson GG, Eliasziw M, Barr HW, et al. The North American Symptomatic
Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke 1999;30:1751–8.
Lal BK, Hobson RW II. Management of carotid restenosis. J Cardiovasc Surg
2006;47:153–60.
Gagne PJ, Riles TS, Jacobowitz GR, et al. Long-term follow-up of patients undergoing
reoperation for recurrent carotid artery disease. J Vasc Surg 1993;18:991–8.
Marone EM, Coppi G, Tshomba Y, et al. Eight-year experience with carotid artery
stenting for correction of symptomatic and asymptomatic post-endarterectomy
defects. J Vasc Surg 2010;52:1511–7.
New G, Roubin GS, Iyer SS, et al. Safety, efficacy, and durability of carotid artery
stenting for restenosis following carotid endarterectomy: a multicenter study.
J Endovasc Ther 2000;7:345–52.
Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus
endarterectomy in high-risk patients. N Engl J Med 2004;351:1493–501.
Schwartz NE, Vertinsky AT, Hirsch KG, et al. Clinical and radiographic natural history
of cervical artery dissections. J Stroke Cerebrovasc Dis 2009;18:416–23.
Redekop GJ. Extracranial carotid and vertebral artery dissection: a review. Can J
Neurol Sci 2008;35:146–52.
Fava M, Meneses L, Loyola S, et al. Carotid artery dissection: endovascular
treatment. Report of 12 patients. Catheter Cardiovasc Interv 2008;71:694–700.
Curtis JA, Johansen K. Techniques in carotid artery surgery. Neurosurg Focus
2008;24:E18.
Spetzler RF, Martin N, Hadley MN, et al. Microsurgical endarterectomy under
barbiturate protection: a prospective study. Br J Neurosurg 1986;65:63–73.

Copyright 2013 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit
http://group.bmj.com/group/rights-licensing/permissions.
BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.
Become a Fellow of BMJ Case Reports today and you can:
▸ Submit as many cases as you like
▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles
▸ Access all the published articles
▸ Re-use any of the published material for personal use and teaching without further permission
For information on Institutional Fellowships contact consortiasales@bmjgroup.com
Visit casereports.bmj.com for more articles like this and to become a Fellow

4

Doss VT, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010766