Postoperative Internal Carotid Artery Twisting with Recurrent Subocclusive Vessel Narrowing After Eversion Endarterectomy: Management with Balloon Angioplasty, Aspiration Thrombectomy, and Repeated Stenting

Endovascular and surgical techniques are commonly used to treat carotid artery stenosis with the goal of preventing emboli and hemodynamic compromise caused by carotid disease and reducing the risk of future stroke. Both procedures are generally associated with low overall morbidity and mortality. Intra- or perioperative complications can have a significant impact on the hospital course and both short- and long-term outcomes. Early postoperative neurological events in patients following carotid endarterectomy should be considered as potentially related to problems at the endarterectomy site, such as thrombosis or an intimal flap, until other causes have been ruled out. However, it is also important to evaluate the surgical site for technical defects, rule out intracranial hemorrhage, and identify other treatable causes such as large vessel occlusion. Carotid artery stenting is a safe and effective option for the management of perioperative vascular complications after surgical revascularization. A 77-year-old female patient underwent eversion endarterectomy for severe right internal carotid artery (ICA) stenosis. Five minutes after carotid clamping, the patient developed neurological symptoms (left-sided arm paresis), and a shunt was inserted. The symptom immediately resolved but returned as soon as the shunt needed to be removed for 2 min. After carotid reperfusion, the patient again became neurological asymptomatic. Intraoperative angiography showed the development of a new mild mid-cervical ICA stenosis, which was interpreted as vasospasm caused by the shunt. She remained asymptomatic postoperatively. The next day, duplex ultrasound showed irregular flow in the reconstruction, and a digital subtraction angiography (DSA) was indicated. Digital subtraction angiography showed a de novo stenosis distal to the site of the stenosis on intraoperative angiography. This “cranial migration” and worsening of the cervical carotid stenosis were associated with new thrombus formation. Endovascular treatment with balloon angioplasty and stenting was straightforward and successful. The following day, she developed new neurological deficits with left-sided hemiparesis and dysarthria. Computed tomography showed another de novo stenosis of the ICA with thrombus formation proximal to the implanted stent and significant hypoperfusion in the right middle and anterior cerebral artery supply territories. Urgent endovascular recanalization with aspiration thrombectomy and overlapping stent implantation was performed. Postprocedural, her clinical condition improved, and she was discharged without residual neurological deficit. We report the case of an early postoperative vascular complication with subocclusive thrombus after carotid endarterectomy due to intraoperative twisting of the artery that was successfully treated with balloon angioplasty, aspiration thrombectomy, and stenting.