Article Text
Abstract
Introduction In patients with significant circumferential calcified carotid stenosis who are not endarterectomy candidates, carotid artery stenting (CAS) is challenged by the inability of stent radial forces to overcome the calcification. Intravascular lithotripsy fractures the plaque rendering it more amenable to angioplasty and stenting. This technique has not yet been reported in the neurosurgical literature.
Objective To provide a technical report on carotid intravascular lithotripsy for calcified carotid artery stenosis, and report a series of two patients who underwent lithotripsy and carotid artery stenting with angioplasty.
Methods Under anesthesia monitored care, right distal radial artery access with a 7F sheath was established using ultrasound guidance. A Benchmark BMX® 81 catheter was navigated to the carotid bifurcation. Therapeutic anticoagulation was initiated, and a distal embolic protection device was deployed. A 5 mm ShockWave lithotripsy balloon was deployed and sonic pulses were delivered (1–2 episodes of one minute duration). An Xact™ or Precise® carotid stent was deployed, and post processing was performed with balloon angioplasty. Post-procedurally, patients were admitted for routine monitoring, placed on daily dual antiplatelet therapy, and baseline ultrasonography was obtained.
Results Patient 1 was an 81-year-old male who presented with a right visual field disturbance and was found to have right hemispheric watershed punctate infarcts. CTA demonstrated >80% right ICA stenosis. Patient 2 was a 77-year-old male who experienced a visual transient ischemic attack and was found to have 90% right ICA stenosis. Patient 3 was an 81-year-old male who presented with forgetfulness and found to have 90% right ICA stenosis. Patient 4 was a 72-year-old female who presented left hemiplegia, facial droop and dysarthria with >95% RICA stenosis. In all patients, there was no significant residual stenosis following in-stent balloon angioplasty. There were no thromboembolic events or neurologic exam changes. Ultrasound demonstrated stent patency and normal peak systolic velocities. All patients have been followed serially in our stroke program without recurrent symptoms.
Conclusion Adjunctive intravascular lithotripsy in patients with severe circumferential calcified stenosis is a novel technique. This application of intravascular lithotripsy warrants further study in an experimental fashion.
Disclosures L. Verhey: None. N. Taylor: None. A. Restrepo Orozco: None. A. Sewell: None. P. Mazaris: None. J. Singer: None.