Author + information
- Received October 21, 2012
- Accepted October 26, 2012
- Published online April 1, 2013.
- ↵⁎Reprint requests and correspondence:
Dr. Pascal J. Mosimann, University Hospital of Lausanne, Department of Radiology, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
A 65-year-old patient with a history of smoking, hypercholesterolemia, and coronary stenting after myocardial infarction was referred for carotid stenting due to recurrent episodes of transient aphasia and right-sided weakness, despite best medical therapy—including aspirin and statins. Magnetic resonance and computed tomography angiography (not shown) displayed punctiform areas of restricted diffusion in the left middle cerebral artery territory and a calcified sub-occlusive stenosis at the origin of the left internal carotid artery. An angiogram confirmed a >95% stenosis (Fig. 1A, arrow). After placing a distal cerebral protection device (DCPD)—or filter—in the subpetrosal segment of the internal carotid artery, angioplasty and stenting were successfully performed. An embolus, however, was observed between the stent and the filter (arrow, Fig. 1B). Hard material was found inside the extracted device (Fig. 1C), corresponding to calcified plaque debris (Fig. 1D). The patient was discharged home 3 days after uneventful observation.
Although DCPDs carry a potential risk of intimal damage and microemboli during filter deployment and retrieval, a systematic review of the published data comparing >23,000 protected and unprotected carotid stenting patients showed that their use significantly decreased the risk of perioperative stroke (1). The type of device, however, does not appear to influence outcome or the percentage of post-procedural embolic lesions (2,3). Patients with high-risk, lipid-rich plaques may, however, benefit more from proximal protection devices and flow reversal, as these seem to significantly reduce periprocedural microembolic events compared to DCPDs (3). Our case demonstrates that seemingly stable, lipid-poor, calcified plaques should be approached with the same degree of caution.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 21, 2012.
- Accepted October 26, 2012.
- American College of Cardiology Foundation
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