Endovascular Salvage of a Displaced Carotid Filter
A patient with multiple comorbidities undergoes successful carotid artery stenting.
A 75-year-old man with a history of atrial fibrillation, hypertension, diabetes mellitus, coronary artery disease, and congestive heart failure was found to have a left carotid bruit. Duplex sonography revealed an 80% to 99% stenosis of the left internal carotid artery (ICA). This finding was confirmed on carotid arteriography, which revealed a high-grade stenosis of the left ICA with dystrophic calcification and shallow ulceration (Figure 1). Given these findings and the patientÕs multiple comorbidities, the patient was selected to undergo carotid artery stenting.
Arterial access was obtained via the right common femoral artery, and an 8-F sheath was subsequently inserted. The left common carotid artery was then selectively catheterized with a 5-F diagnostic HN1 catheter (Cook Medical, Bloomington, IN). This was followed by passage of a Wholey wire (Covidien, Mansfield, MA) to the external carotid artery followed by passage of the diagnostic catheter. The Wholey wire was then removed and replaced with a tapered Amplatz wire (Cook Medical). The diagnostic catheter was removed and replaced by the 8-F multipurpose guide catheter. After positioning of the guide just proximal to the bifurcation, the Accunet filter was then passed across the tight stenotic target lesion, and the filter was deployed in the high cervical segment of the ICA.
The lesion was then predilated with a 4-mm X 2-cm Maverick (Boston Scientific Corporation, Natick, MA) coronary balloon. A tapered 6-mm X 8-mm X 3-cm Acculink endovascular stent (Abbott Vascular) was then deployed, which was followed by postdilatation with a 5-mm, low-profile Maverick coronary balloon. At completion arteriography, there were satisfactory dimensions through the target lesion site with substantial improvement in flow (Figure 2).
The Accunet filter was in the process of being removed when detachment occurred, and the filter was displaced distally in the ICA (Figure 3). The filter wire was removed, and the patient was maintained on bivalirudin. The filter remained patent, and normal intracranial circulation was noted on arteriography (Figure 4). Vascular surgical and neurosurgical consults were then obtained regarding potential removal of the filter; it was determined that the filter was in too distal a segment of the ICA for safe surgical removal. Snaring was not an option considering that the distal portions of the tines were not radiographically visible. The detached basket was at the base of the skull at the petrosal segment of the ICA.
The decision was made to proceed with endovascular treatment to compress and secure the filter. A PT2 steerable .014-inch wire (Boston Scientific Corporation) was subsequently passed outside of the basket around the lesion and positioned at the level of the cavernous sinus segment (Figure 5). A 32-mm X 3.5-mm Taxus stent (Boston Scientific Corporation) was then expanded to 18 atm at the filter site, with resultant collapse of the filter (Figure 6). There was no evidence of any compromise to the intracranial circulation. The patient tolerated the procedure satisfactorily with no untoward neurologic reactions.
The patient was discharged on hospital day 1 and recovered uneventfully. He remained without any neurologic sequelae at 1-year follow-up.
Donald T. Baril, MD, is a Fellow in Vascular and Endovascular Surgery, University of Pittsburgh Medical Center, in Pittsburgh, Pennsylvania. He has disclosed that he holds no financial interest in any product or manufacturer mentioned herein. Dr. Baril may be reached at (412) 802-3031; firstname.lastname@example.org.
Mark H. Wholey, MD, is Director, Cardiovascular and Interventional Radiology, Shadyside Hospital, University of Pittsburgh Medical Center, in Pittsburgh, Pennsylvania. He has disclosed that he is a consultant for Covidien. Dr. Wholey may be reached at (412) 623-2083; email@example.com.