Thrombus Aspiration and Sequential Thrombus Aspiration and Sequential Stenting in Bilateral Carotid Arteries Stenting in Bilateral Carotid Arteries

for a Patient with Takayasu Arteritisfor a Patient with Takayasu Arteritis

Tianjin First Center Hospital Tianjin First Center Hospital

Lu Chengzhi Guo qianyu Chen xinLu Chengzhi Guo qianyu Chen xin

天津市第一中心医院心内科天津市第一中心医院心内科卢成志 郭倩玉 陈欣卢成志 郭倩玉 陈欣

HistoryHistory

FemaleFemale ，， 36 years old36 years old

Chief complaint: intermittent amaurosis for Chief complaint: intermittent amaurosis for one month, arose from exertion, one month, arose from exertion, accompanied with tumbling accompanied with tumbling

Past history: Takayasu arteritis and Past history: Takayasu arteritis and pulmonary fibrosis for 3 years under oral pulmonary fibrosis for 3 years under oral prednisone managementprednisone management

Physical ExaminationPhysical Examination

RUE/LUE pulseless, LLE pressure 170/80 RUE/LUE pulseless, LLE pressure 170/80 mmHg, RLE pressure 130/80 mmHgmmHg, RLE pressure 130/80 mmHg

III/6 systolic murmurs in left carotid artery. III/6 systolic murmurs in left carotid artery. Both lung clear. HR 72 bpmBoth lung clear. HR 72 bpm ，， regular regular rhythm, no murmurs.rhythm, no murmurs.

Laboratory InvestigationsLaboratory Investigations

Blood RtBlood Rt ：： Hb 110g/L WBC6.1X10Hb 110g/L WBC6.1X109/L9/L

Liver function and renal function: normalLiver function and renal function: normal TC 6.31mmol/L TG 1.64mmol/LTC 6.31mmol/L TG 1.64mmol/LESRESR ：： 18mm/h18mm/hCRPCRP ： ： 0.76mg/dl 0.76mg/dl Immune antibodiesImmune antibodies ：：

SSB(+)SSB(+) SSA(+)SSA(+) ANA: 1ANA: 1 ：： 100100 others:(-)others:(-)

Auxiliary ExaminationsAuxiliary Examinations

ECGECG ：： normalnormal

UCG: normalUCG: normal

Angiography ExaminationAngiography Examination

CAGCAG ：： 40% stenosis in LM ostium40% stenosis in LM ostium LAD normalLAD normal LCX normalLCX normal RCA normalRCA normal

Ceberal angiography:Ceberal angiography: ：： Brachiocephalic trunk occlusive.Brachiocephalic trunk occlusive. Left carotid artery subtotal occlusive.Left carotid artery subtotal occlusive. Left subclavian artery: 90% stenosisLeft subclavian artery: 90% stenosis left vertebral artery: 95% stenosis in ostiumleft vertebral artery: 95% stenosis in ostium

Brachiocephalic trunk occlusiveBrachiocephalic trunk occlusive

Left carotid artery subtotal occlusiveLeft carotid artery subtotal occlusive

Left subclavian artery: 90% stenosisLeft subclavian artery: 90% stenosisleft vertebral artery: 95% stenosis in ostiumleft vertebral artery: 95% stenosis in ostium

Treatment strategyTreatment strategy

Conservative therapy?Conservative therapy?

Interventional therapy?Interventional therapy?

Carotidendarterectomy? Carotidendarterectomy?

Treatment strategyTreatment strategy

MedicationMedication ：： prednisone prednisone cyclophophamidecyclophophamide

Interventional therapyInterventional therapy ：： first step: stent in right carotid arteryfirst step: stent in right carotid artery second step: stent in left carotid arterysecond step: stent in left carotid artery

Stenting in right carotid arteryStenting in right carotid artery （（ 2009-05-252009-05-25 ））

ApproachApproach ：： right femoral arteryright femoral arteryEquipmentEquipment ：：

8F MPA1 Guiding catheter8F MPA1 Guiding catheter guide wireguide wire distal end protective umbrelladistal end protective umbrella 2.0×20mm×mm Avion balloon2.0×20mm×mm Avion balloon thrombus aspiration catheter thrombus aspiration catheter 5.0×40mm Submarine balloon5.0×40mm Submarine balloon 7.0×40mm Precise stent7.0×40mm Precise stent

2.0×20 balloon dilation2.0×20 balloon dilation After dilationAfter dilation

Distal end potective unmbrella 5.0×40mm balloon5.0×40mm balloon

After thrombus aspiration

Thrombus

before aspiration

7.0×40 Precise stent7.0×40 Precise stent Post dilation

Final result

Postoperative treatmentPostoperative treatment

Aspirin 300 mg and clopidogrel 75 mgAspirin 300 mg and clopidogrel 75 mg

Nifedipine to control BPNifedipine to control BP

PrednisonePrednisone

The patient’s ESR rose transiently and The patient’s ESR rose transiently and then fell normal, she didn’t feel dizziness then fell normal, she didn’t feel dizziness or amaurosis any more. or amaurosis any more.

Stenting in left carotid arteryStenting in left carotid artery （（ 2009-06-222009-06-22 ））

ApproachApproach ：： right femoral arteryright femoral arteryEquipmentEquipment ：：

8F MPA1 Guiding catheter8F MPA1 Guiding catheter 2 guide wire2 guide wire 2.0×20mm×mm Invatec balloon2.0×20mm×mm Invatec balloon distal end protective umbrelladistal end protective umbrella 5.0×30mm Invatec balloon5.0×30mm Invatec balloon 7.0×40mm Cordis stent7.0×40mm Cordis stent

2.0×20mm×mm Invatec balloon2.0×20mm×mm Invatec balloonBefore operationright carotid artery

5.0×30mm Invatec balloon5.0×30mm Invatec balloon 7.0×40mm Cordis stent7.0×40mm Cordis stent Final result

DiscussionDiscussion

Endovascular interventional therapy:Endovascular interventional therapy: an approach to an approach to occlusive lesion of arteritis: Is it a suitable option?occlusive lesion of arteritis: Is it a suitable option?

Thrombus aspirationThrombus aspiration: the first attempt dealing with : the first attempt dealing with thrombotic complications of stenting in carotid: Is it a thrombotic complications of stenting in carotid: Is it a lucky hit or a mandatory practice?lucky hit or a mandatory practice?

medication or stenting in subclavian arterymedication or stenting in subclavian artery: Is it done or : Is it done or overdone?overdone?

Antiplatlete therapyAntiplatlete therapy: duration and dosage.: duration and dosage.

Follow upFollow up

No dizzness or amaurosis until now No dizzness or amaurosis until now ESR 15-25 mmESR 15-25 mmMedication: Medication:

prednisone 5 mg QDprednisone 5 mg QD Aspirin 100 mg Aspirin 100 mg clopidogrel 75 mg QD for 6 Months clopidogrel 75 mg QD for 6 Months

8 month later CTA examination8 month later CTA examination

8 months later CTA show restenosis8 months later CTA show restenosis

Stent in right carotid artery

Stent in left carotid artery

DiscussionDiscussion

What to do with restenosis now: What to do with restenosis now:

Intervention: bilateral balloon dilation?Intervention: bilateral balloon dilation?

Conservative treatment?Conservative treatment?

Carotidendarterectomy? Carotidendarterectomy?