DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Symptomatic critically severe left carotid stenosis.
2. Right internal carotid artery occlusion.
3. Right vertebral artery occlusion.
POSTOPERATIVE DIAGNOSES:
1. Symptomatic critically severe left carotid stenosis.
2. Right internal carotid artery occlusion.
3. Right vertebral artery occlusion.
PROCEDURES PERFORMED:
1. Thoracic arteriogram.
2. Selective right carotid arteriography.
3. Selective left carotid arteriography.
4. Selective left vertebral arteriography.
SURGEON: John Doe, MD
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.
PROCEDURE FINDINGS:
1. Heavily calcified plaque at the origin of the right innominate.
2. Mild stenosis, origin of the left common carotid artery.
3. Right vertebral artery occlusion.
4. Right internal carotid artery occlusion.
5. EC-IC collateralization with filling of the right middle cerebral and anterior cerebral arteries from the external carotid artery on the right.
6. No evidence of a patent anterior communicating artery.
7. Patent posterior communicating artery on the left.
8. Normal filling of the vertebrobasilar system from the left vertebral artery with some collateralization to the left MCA via the patent posterior communicating artery.
9. Critically severe 98% stenosis of the left internal carotid artery at the bifurcation with slow flow in the cervical internal carotid artery because of the severity of the stenosis. Evidence of patent internal cerebral and internal carotid artery with delayed but present filling of the left MCA from the left carotid injection.
DESCRIPTION OF PROCEDURE: The patient was brought to the endovascular suite and placed in the supine position on the angio table. The right groin was sterilely prepped and draped in the usual fashion. The right groin was anesthetized with 1% lidocaine without epinephrine local anesthetic. The patient was given minimal intravenous sedation to keep him completely awake, alert and responsive during the carotid angiography to allow for neuro examination.
A microneedle access technique was used in the right femoral artery and a 5 French sheath was placed in retrograde fashion in the right femoral artery. A 5 French pigtail catheter was advanced over a wire and reformed in the ascending aorta. An arteriogram was obtained in the 35-degree LAO and 35-degree RAO oblique positions for imaging of the arch to evaluate the disease at the origin of the innominate and the left common carotid arteries. The pigtail catheter was exchanged for a 3DRC catheter, which was reformed and selectively advanced into the right common carotid artery from the right innominate.
Selective right carotid angiography was performed and angio was obtained in the AP and lateral cervical and AP and lateral cerebral views. There was excellent filling of the right middle cerebral artery and the right anterior cerebral artery from EC-IC collaterals from the right external carotid artery. There was no evidence of cross filling to the left cerebral hemisphere. No evidence of a patent anterior communicating artery.
The 3DRC catheter was withdrawn into the arch and selectively passed into the left common carotid artery. AP and lateral cervical and AP and lateral left cerebral arteriograms were obtained through hand injection 3DRC catheter. This revealed the critically severe nature of the stenosis of the origin of the left internal carotid artery. There was intraluminal filling defect within the midst of the most severe portion of the stenosis.
It was impossible to determine from this angiographic evaluation whether that intraluminal filling defect represented complex plaque or actual thrombus in the lumen just behind the high-grade stenosis of the internal carotid artery. Therefore, it was felt that guidewire traversal across this lesion for placement of the distal cerebral perfusion protection device would not be advisable, and therefore, the patient would be at high risk for CAS.
Instead, the patient will be taken for a therapeutic left carotid endarterectomy. The 3DRC catheter was then withdrawn from the common carotid into the arch and selectively matched in the left subclavian artery and using row-mapping technique over a 0.035 wire selectively advanced into the left vertebral artery. There was moderate orificial left vertebral artery stenosis. However, there were no distal tandem lesions in the left vertebral artery. There was patent posterior communicating artery on the left.
The 3DRC catheter was withdrawn into the arch and removed over wire. A femoral arteriogram was obtained, which confirmed good placement of the sheath for use of Angio-Seal closure device. The Angio-Seal was used. Good hemostasis was obtained. The patient was returned to the recovery room.
