Clinical Review & Education
JAMA Surgery Clinical Challenge
Symptomatic Carotid Stenosis Reshma Brahmbhatt, MD; Ravi Veeraswamy, MD; Shipra Arya, MD, SM
A
A
B
P
Figure 1. Sagittal view demonstrates the left internal carotid stenosis (A indicates anterior; P, posterior) (A) and the distal extent of the findings (arrowhead) (B).
A woman in her early 60s with a history of hypertension and hyperlipidemia was transferred to our hospital after multiple transient ischemic attacks and left internal carotid artery (ICA) stenosis during the past several months. Her most recent presentation was 1 week prior for a minor stroke with Quiz at jamasurgery.com amaurosis fugax, slurred speech, rightsided weakness, and facial droop lasting longer than 24 hours. Magnetic resonance imaging of the brain demonstrated subacute infarctions involving the left frontal and parietal hemispheres. She was a current smoker and was taking aspirin and statin medication at the time of presentation. Workup at another facility prior to transfer included computed tomographic angiography of the neck, which showed chronic occlusion of the right ICA and 95% stenosis of the left ICA. On examination, the patient was afebrile with a heart rate of 69 beats/min and blood pressure of 134/69 mm Hg. Pertinent findings included no carotid bruit, a regular cardiac rhythm, and equally palpable upper extremity pulses bilaterally. The patient was neurologically intact, save for 4/5 motor strength in her right upper extremity. Computed tomographic angiography of the head and neck was performed (Figure 1).
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WHAT IS YOUR DIAGNOSIS?
A. Trapped air embolus B. Free-floating arterial thrombus C. Ruptured arterial plaque D. Radiographic artifact
JAMA Surgery January 2015 Volume 150, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Florida International University Medical Library User on 05/25/2015
79
Clinical Review & Education JAMA Surgery Clinical Challenge
Diagnosis B. Free-floating arterial thrombus
Discussion Preoperative imaging revealed a severe (>70%) left ICA stenosis with a portion of free-floating thrombus (FFT) distally. We placed the patient on a heparin infusion. Owing to the high risk of recurrent stroke and contralateral ICA occlusion, we felt surgical intervention was indicated. The high bifurcation, distal FFT up to the second cervical vertebral level, potential for jaw subluxation, short neck and body habitus, and need for intraoperative shunt (contralateral ICA occlusion) made carotid endarterectomy anatomically a high-risk option. After extensive discussion with the patient, we proceeded with a left carotid stent with cerebrovascular protection. We traversed the stenosis and thrombus with a 0.014inch filter wire with no resistance (SpiderFX) and placed a
Figure 2. Angiogram of the left internal carotid artery following stent placement.
ARTICLE INFORMATION Author Affiliations: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia. Corresponding Author: Shipra Arya, MD, SM, Emory University, 101 Woodruff Cir, 5105 WMB, Atlanta, GA 30322 ([email protected]). Section Editor: Pamela A. Lipsett, MD, MHPE. Published Online: November 26, 2014. doi:10.1001/jamasurg.2014.376. Conflict of Interest Disclosures: None reported. REFERENCES 1. Combe J, Poinsard P, Besancenot J, et al. Free-floating thrombus of the extracranial internal carotid artery. Ann Vasc Surg. 1990;4(6):558-562.
80
6 × 8 × 30-mm nitinol stent (Figure 2). The patient’s neurological status was confirmed at each step. Biplanar imaging was used to obtain prestenting and poststenting carotid and cerebral angiograms to rule out any distal embolization. The patient was discharged home the following day. She is symptom free with a patent stent at 6-week follow-up. Free-floating thrombus is an uncommon entity with an incidence rate of 0.05% to 0.7% in symptomatic patients.1 The most commonly used definition is an elongated thrombus attached to the arterial wall with circumferential blood flow at its distal-most aspect and cyclical motion with cardiac cycles.2 The cause of FFT is usually atherosclerotic plaque (75% of cases), but 47% of patients have hypercoagulable states.2 Diagnosis is made via conventional angiography, computed tomographic angiography, or duplex ultrasonography.2-4 Lesions extending more than 3.8 mm craniocaudally are more likely to represent FFT than ulcerated plaque.5 Treatment can consist of anticoagulation only, as shown by multiple case reports.2,3,6 However, surgical intervention is indicated in patients with underlying significant stenosis, recurrent symptoms, inability to undergo anticoagulation, or thrombus progression. Common risks to all interventions include distal embolization and potential thrombosis. Carotid endarterectomy has been the standard surgical therapy, with good reported results.1,3 Techniques for FFT treatment include distal isolation of the ICA without touching the bulb and thrombus retrieval through back-bleeding control and removal of residual thrombus manually or with a Fogarty catheter.4 Positive results have also been described with endovascular techniques, including carotid stenting, suction removal of the thrombus, and coiling of the affected artery.6,7 For carotid stenting, we used perioperative anticoagulation, low-profile devices, minimal bulb manipulation before deployment of the filter, and gentle postballoon dilation as strategies to avoid those risks. Neurointerventional help was available in the event of distal embolization. Flow reversal technique can also be used in these situations and has the theoretical advantage of not crossing the lesion prior to establishing distal protection. However, there is a possibility of transient ischemic attack/stroke or intolerance to flow reversal with contralateral ICA occlusion.8
2. Bhatti AF, Leon LR Jr, Labropoulos N, et al. Free-floating thrombus of the carotid artery: literature review and case reports. J Vasc Surg. 2007;45(1):199-205.
6. Vellimana AK, Kadkhodayan Y, Rich KM, et al. Symptomatic patients with intraluminal carotid artery thrombus: outcome with a strategy of initial anticoagulation. J Neurosurg. 2013;118(1):34-41.
3. Delgado MG, Vega P, Roger R, Bogousslavsky J. Floating thrombus as a marker of unstable atheromatous carotid plaque. Ann Vasc Surg. 2011; 25(8):e11-e17.
7. Park JW, Lee DH, Choi CG, Kim SJ, Suh DC. Various endovascular approaches to the management of free floating carotid thrombi: a technical report. J Neurointerv Surg. 2012;4(5): 336-338.
4. Ferrero E, Ferri M, Viazzo A, et al. Free-floating thrombus in the internal carotid artery: diagnosis and treatment of 16 cases in a single center. Ann Vasc Surg. 2011;25(6):805-812. 5. Jaberi A, Lum C, Stefanski P, et al. Computed tomography angiography intraluminal filling defect is predictive of internal carotid artery free-floating thrombus. Neuroradiology. 2014;56(1):15-23.
8. Criado E, Fontcuberta J, Orgaz A, Flores A, Doblas M. Transcervical carotid stenting with carotid artery flow reversal: 3-year follow-up of 103 stents. J Vasc Surg. 2007;46(5):864-869.
JAMA Surgery January 2015 Volume 150, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Florida International University Medical Library User on 05/25/2015
jamasurgery.com
JAMA Surgery Clinical Challenge
Symptomatic Carotid Stenosis Reshma Brahmbhatt, MD; Ravi Veeraswamy, MD; Shipra Arya, MD, SM
A
A
B
P
Figure 1. Sagittal view demonstrates the left internal carotid stenosis (A indicates anterior; P, posterior) (A) and the distal extent of the findings (arrowhead) (B).
A woman in her early 60s with a history of hypertension and hyperlipidemia was transferred to our hospital after multiple transient ischemic attacks and left internal carotid artery (ICA) stenosis during the past several months. Her most recent presentation was 1 week prior for a minor stroke with Quiz at jamasurgery.com amaurosis fugax, slurred speech, rightsided weakness, and facial droop lasting longer than 24 hours. Magnetic resonance imaging of the brain demonstrated subacute infarctions involving the left frontal and parietal hemispheres. She was a current smoker and was taking aspirin and statin medication at the time of presentation. Workup at another facility prior to transfer included computed tomographic angiography of the neck, which showed chronic occlusion of the right ICA and 95% stenosis of the left ICA. On examination, the patient was afebrile with a heart rate of 69 beats/min and blood pressure of 134/69 mm Hg. Pertinent findings included no carotid bruit, a regular cardiac rhythm, and equally palpable upper extremity pulses bilaterally. The patient was neurologically intact, save for 4/5 motor strength in her right upper extremity. Computed tomographic angiography of the head and neck was performed (Figure 1).
jamasurgery.com
WHAT IS YOUR DIAGNOSIS?
A. Trapped air embolus B. Free-floating arterial thrombus C. Ruptured arterial plaque D. Radiographic artifact
JAMA Surgery January 2015 Volume 150, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Florida International University Medical Library User on 05/25/2015
79
Clinical Review & Education JAMA Surgery Clinical Challenge
Diagnosis B. Free-floating arterial thrombus
Discussion Preoperative imaging revealed a severe (>70%) left ICA stenosis with a portion of free-floating thrombus (FFT) distally. We placed the patient on a heparin infusion. Owing to the high risk of recurrent stroke and contralateral ICA occlusion, we felt surgical intervention was indicated. The high bifurcation, distal FFT up to the second cervical vertebral level, potential for jaw subluxation, short neck and body habitus, and need for intraoperative shunt (contralateral ICA occlusion) made carotid endarterectomy anatomically a high-risk option. After extensive discussion with the patient, we proceeded with a left carotid stent with cerebrovascular protection. We traversed the stenosis and thrombus with a 0.014inch filter wire with no resistance (SpiderFX) and placed a
Figure 2. Angiogram of the left internal carotid artery following stent placement.
ARTICLE INFORMATION Author Affiliations: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia. Corresponding Author: Shipra Arya, MD, SM, Emory University, 101 Woodruff Cir, 5105 WMB, Atlanta, GA 30322 ([email protected]). Section Editor: Pamela A. Lipsett, MD, MHPE. Published Online: November 26, 2014. doi:10.1001/jamasurg.2014.376. Conflict of Interest Disclosures: None reported. REFERENCES 1. Combe J, Poinsard P, Besancenot J, et al. Free-floating thrombus of the extracranial internal carotid artery. Ann Vasc Surg. 1990;4(6):558-562.
80
6 × 8 × 30-mm nitinol stent (Figure 2). The patient’s neurological status was confirmed at each step. Biplanar imaging was used to obtain prestenting and poststenting carotid and cerebral angiograms to rule out any distal embolization. The patient was discharged home the following day. She is symptom free with a patent stent at 6-week follow-up. Free-floating thrombus is an uncommon entity with an incidence rate of 0.05% to 0.7% in symptomatic patients.1 The most commonly used definition is an elongated thrombus attached to the arterial wall with circumferential blood flow at its distal-most aspect and cyclical motion with cardiac cycles.2 The cause of FFT is usually atherosclerotic plaque (75% of cases), but 47% of patients have hypercoagulable states.2 Diagnosis is made via conventional angiography, computed tomographic angiography, or duplex ultrasonography.2-4 Lesions extending more than 3.8 mm craniocaudally are more likely to represent FFT than ulcerated plaque.5 Treatment can consist of anticoagulation only, as shown by multiple case reports.2,3,6 However, surgical intervention is indicated in patients with underlying significant stenosis, recurrent symptoms, inability to undergo anticoagulation, or thrombus progression. Common risks to all interventions include distal embolization and potential thrombosis. Carotid endarterectomy has been the standard surgical therapy, with good reported results.1,3 Techniques for FFT treatment include distal isolation of the ICA without touching the bulb and thrombus retrieval through back-bleeding control and removal of residual thrombus manually or with a Fogarty catheter.4 Positive results have also been described with endovascular techniques, including carotid stenting, suction removal of the thrombus, and coiling of the affected artery.6,7 For carotid stenting, we used perioperative anticoagulation, low-profile devices, minimal bulb manipulation before deployment of the filter, and gentle postballoon dilation as strategies to avoid those risks. Neurointerventional help was available in the event of distal embolization. Flow reversal technique can also be used in these situations and has the theoretical advantage of not crossing the lesion prior to establishing distal protection. However, there is a possibility of transient ischemic attack/stroke or intolerance to flow reversal with contralateral ICA occlusion.8
2. Bhatti AF, Leon LR Jr, Labropoulos N, et al. Free-floating thrombus of the carotid artery: literature review and case reports. J Vasc Surg. 2007;45(1):199-205.
6. Vellimana AK, Kadkhodayan Y, Rich KM, et al. Symptomatic patients with intraluminal carotid artery thrombus: outcome with a strategy of initial anticoagulation. J Neurosurg. 2013;118(1):34-41.
3. Delgado MG, Vega P, Roger R, Bogousslavsky J. Floating thrombus as a marker of unstable atheromatous carotid plaque. Ann Vasc Surg. 2011; 25(8):e11-e17.
7. Park JW, Lee DH, Choi CG, Kim SJ, Suh DC. Various endovascular approaches to the management of free floating carotid thrombi: a technical report. J Neurointerv Surg. 2012;4(5): 336-338.
4. Ferrero E, Ferri M, Viazzo A, et al. Free-floating thrombus in the internal carotid artery: diagnosis and treatment of 16 cases in a single center. Ann Vasc Surg. 2011;25(6):805-812. 5. Jaberi A, Lum C, Stefanski P, et al. Computed tomography angiography intraluminal filling defect is predictive of internal carotid artery free-floating thrombus. Neuroradiology. 2014;56(1):15-23.
8. Criado E, Fontcuberta J, Orgaz A, Flores A, Doblas M. Transcervical carotid stenting with carotid artery flow reversal: 3-year follow-up of 103 stents. J Vasc Surg. 2007;46(5):864-869.
JAMA Surgery January 2015 Volume 150, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Florida International University Medical Library User on 05/25/2015
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