Carotid Artery Stenting for Recurrently Symptomatic Carotid Web: An Uncomplicated and Efficient Procedure

The carotid web is an intimal and non-circumferential variant of fibromuscular dysplasia located at the origin of the carotid bulb. It is increasingly recognized as a potential etiology of cryptogenic stroke. The accepted mechanism of cerebral ischemic events is an artery-to-artery embolism caused by flow disruption and blood statis caused by protrusion of the web into the lumen of the carotid artery. Symptomatic carotid web seems to be associated with a high risk of stroke recurrence, and medicinal options have provided only limited protection. Accordingly, a growing number of patients are referred for invasive treatment such as surgery or stenting. A 54-year-old woman with a past medical history of hypothyroidism had been admitted to the Stroke Unit due to a mild embolic left-hemispheric stroke with a National Institutes of Health Stroke Score (NIHSS) of 3 points 6 months earlier. Noncontrast cranial CT at that admission was unremarkable. CTA revealed a shelf-like, linear, thin filling defect located along the posterior wall of the left internal carotid artery (ICA) bulb, suggestive of a carotid web. Cranial MRI confirmed small subcortical subacute infarctions in the left frontal and parietal lobes. The patient was not eligible for the administration of recombinant tissue plasminogen activator (rTPA) due to exhaustion of the therapeutic window, and dual antiplatelet therapy was started. ECG Holter monitoring and transthoracic echocardiogram were unremarkable. The patient made a full recovery and was treated with dual antiplatelet therapy for 3 months, followed by 100 mg aspirin and 80 mg atorvastatin for the long term. Despite compliance with antithrombotic medicinal treatment, she developed a recurrent left-hemispheric stroke, manifested by speech disturbances and mild right-sided hemiparesis. She was admitted to the Emergency Room 1 h after symptom onset with an NIHSS of 5. Admission non-contrast cranial CT was unremarkable. CT angiography revealed findings similar to the previous examination. MRI diffusion-weighted imaging (DWI) revealed a small acute subcortical infarction in the left frontal lobe. The patient was treated by systemic intravenous thrombolysis as per protocol for an acute phase stroke. Repeat non-contrast CT was normal, and the patient had a significant neurological improvement with a follow-up NIHSS of 1 on the second day. Carotid artery stenting as a secondary phrophylactic measure was performed 3 days after this second stroke. The patient had an unremarkable clinical course and was discharged completely asymptomatic on dual antiplatelet therapy. During the last 4 years, the patient has been free of ischemic episodes. This chapter describes the carotid web, focusing on the diagnosis and presenting the available therapeutic options. Endovascular treatment is usually rapid, straightforward, uncomplicated, and effective in preventing recurring ischemic events. Stenting is the preferred and commonly used approach in our center. We describe our standard procedure and present a glimpse of controversies and ongoing debates.