Clinical Instability and Watershed Infarction Due to Ostial Stenosis of the Left Common Carotid Artery: Filter-Protected Balloon-Expandable Stent-Assisted Common Carotid Artery Angioplasty with Excellent Angiographic and Clinical Results

The incidence of significant stenosis or occlusion affecting the origins of the aortic arch branch vessels is close to 4%. The vast majority of the current literature is focused on the management of internal carotid artery (ICA) disease, with a relative lack regarding the management of common carotid artery (CCA) steno-occlusive disease. Data on endovascular treatment of CCA lesions are scarce, and evidence regarding the management options for CCA steno-occlusive disease is more limited and controversial. The European Society for Vascular Surgery 2017 guidelines recommend open retrograde stenting for symptomatic isolated common carotid stenoses. The transfemoral approach may be unsuccessful in traversing CCA lesions, particularly in patients with elongated aortic arches. However, it is our preferred therapeutic option in uncomplicated aortic arches. A 61-year-old man presented with a history of uncontrolled arterial hypertension, dyslipidemia, coronary heart disease, and heavy smoking. He consulted a neurologist after four episodes of right-hand weakness and speech alterations that had occurred during the previous week. The neurologist sent the patient to the emergency room, where neurological examination confirmed mild motor dysphasia, mild right arm weakness (motor strength grading 4/5), and right Babinski sign. Blood pressure measured on the right arm was 187/105 mmHg compared with 165/96 mmHg on the left arm. Cranial CT showed advanced microvascular disease. CTA showed a stenosis of the origin of the left common carotid trunk, diffuse extra-intracranial atheromatosis, and an isolated left ICA system (aplasia of left A1 and no posterior communicating arteries). Cranial MRI showed advanced microvascular disease, watershed infarctions at border zones between the left middle cerebral artery (MCA) and anterior cerebral artery (ACA), and an embolic infarct in the left frontal lobe. During his hospital stay, aspirin was complemented with clopidogrel, amlodipine, and atorvastatin. Two days after admission, the patient reported worsening of his right arm weakness. His blood pressure was 165/96 mmHg. A diagnostic aortogram confirmed severe near-occlusive stenosis of the origin of the left CCA due to an eccentric atherosclerotic plaque that was causing significant hemodynamic compromise. The trunk beyond the stenosis had a diameter of 6.5 mm. We administered 300 mg of clopidogrel and 300 mg of aspirin, and 90 min later, VerifyNow testing confirmed 118 P2Y12 reaction units (PRU). Under local anesthesia, we introduced an 8F guiding catheter with a multipurpose curved tip via femoral access. We navigated it to a point immediately distal to the origin of the left CCA. A microcatheter was then guided through the stenosis and placed at the left ICA. The microcatheter was exchanged for a Spider filter protection device (Medtronic), which was deployed at the post bulbar ICA. A 7/24 mm balloon-expandable stent was then navigated using the filter wire, placed at the proximal left CCA, and expanded at the trunk lesion at 18 atmospheres for 30 s, with excellent angiographic and clinical results. The patient had an uncomplicated subsequent hospital course with an improvement of his right arm weakness on the day of his angioplasty. He was followed in the neurology clinic for 2 years and continued to be neurologically asymptomatic. This chapter describes the case of a watershed stroke secondary to severe common carotid trunk stenosis in a patient with an incomplete circle of Willis. Protected stent-assisted angioplasty via the femoral route was chosen, achieving excellent angiographic and clinical results. We describe our revascularization strategy, its rationale, and possible limitations.