Neurointervention.  2013 Feb;8(1):52-57. 10.5469/neuroint.2013.8.1.52.

Captured Macro-embolus of Fractured Atheromatous Plaque by the Embolic Protection Device during Carotid Stent Assisted Angioplasty

• Kim MC
• Bennett S
• Farb R
• Croul S
• Lee SK

• KMID: 2052082
• DOI: http://doi.org/10.5469/neuroint.2013.8.1.52

Abstract

The authors present a case in which macro-embolus from the ruptured atheromatous plaque developed during carotid artery stenting (CAS). A 63-year-old man who had suffered a left middle cerebral artery territory infarction had significant proximal left internal carotid artery stenosis required CAS procedure. Immediate after stent deployment, the patient showed abrupt neurological deterioration with 12 x 3 mm sized macro-embolus which was caught by the embolus protection device (EPD). Retrieval of the macro-embolus was performed safely and the patient recovered to pre-procedure status. Macro-embolus can be resulted during the CAS. The EPD can capture the macro-embolus and safe removal is technically feasible.

Keyword

Carotid stenting; Embolus protection device; Atheromatous plaque

MeSH Terms

Angioplasty
Carotid Arteries
Carotid Stenosis
Embolic Protection Devices
Embolism
Humans
Infarction
Middle Cerebral Artery
Stents

Figure

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  Fig. 1 Lateral view of the left CCA angiogram shows about 70% of smooth luminal stenosis without angiographic evidence plaque ulcer or irregularity.

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  Fig. 2 Lateral view of post-angioplasty CCA angiogram shows development of dissection on the atheromatous plaque (arrow).

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  Fig. 3 After stent deployment, the left CCA angiogram AP view (A) shows significant very dense contrast accumulation (*) beyond the spindle shaped filling defect (arrows) captured in the EPD indicating significant slow flow beyond the filling defect. Subsequent intracranial AP view (B) showed slow filling of distal left ICA.

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  Fig. 4 10 minutes after Reopro® infusion, the forward flow through the filling defect shows re-established on the left CCA AP view.

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  Fig. 5 AP spot film during the removal of the Rx-Accunet®, Rx-Accunet Retrieval device 2® and Shuttle® sheath. Note the 4 radio-opaque markers of the Rx-Accunet® are not completely opposed (white arrow heads) and the position of the Shuttle® sheath (arrow) which was advanced until the Rx-Accunet® wires can be straight enough not to be caught by the deployed stent struts.

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  Fig. 6 After the removal of the filling defect, AP view of extracranial (A) and intracranial (B) circulation on the left CCA angiogram show no additional filling defect.

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  Fig. 7 Gross picture (A) of the retrieved filling defect with EPD (removed from its delivery wire) shows spindle shaped 12 × 3 mm sized lesion. Calcium staining of the lesion (arrows) with underlying relative acelluar matrix (B) and Factor-VIII staining (C) for angiogenetic activity (arrows) indicating the lesion is a mature atheromatous plaque.

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