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Transcript of Reocclusion and stroke due to immediate plaque protrusion following endovascular treatment of...
CASE REPORT
Reocclusion and stroke due to immediate plaque protrusionfollowing endovascular treatment of carotid artery successfullytreated with intra-arterial urokinase and stent in stent in a patientwith Takayasu arteritis with severe disease of all arch vessels
B. C. Srinivas • Soumya Patra • Babu Reddy •
C. M. Nagesh • C. N. Manjunath
Received: 9 January 2013 / Accepted: 27 March 2013
� Japanese Association of Cardiovascular Intervention and Therapeutics 2013
Abstract Endovascular treatment is becoming a safe and
efficacious modality in the management of carotid artery
stenosis in Takayasu arteritis (TA). A 24-year-old woman
of TA presented with blurred vision, recurrent syncope and
upper limb claudication. Angiography revealed right CCA
95 %, left CCA 90 % stenosis and occlusion of other arch
vessels. She underwent right CCA angioplasty and stent-
ing. She developed left-sided hemi paresis. Check angio-
gram revealed plaque protrusion in the proximal part of the
stented segment. Intra-arterial urokinase bolus was given
and overlapping stenting done. Re-occlusion by plaque
protrusion immediately after stenting like in our case is not
reported.
Keywords Carotid artery � Endovascular treatment �Intra-arterial urokinase � Plaque protrusion � Takayasu
arteritis
Introduction
Takayasu arteritis (TA) is a chronic inflammatory disease
affecting the aorta and its major branches. The most fre-
quently involved vessels are subclavian arteries, carotid
arteries, descending thoracic or abdominal aorta, and renal
arteries [1]. TA primarily affects young women of child-
bearing age and usually presents with absent radial pulse
and signs of cerebral ischemia [1]. Carotid angioplasty and
stenting are increasingly being used as safe and efficacious
modality of treatment in the management of carotid artery
stenosis [2]. Restenosis rates of percutaneously treated
Takayasu lesions have been higher than those with non-
inflammatory lesions. But so far medline search does not
reveal any case before where patient had post-procedure
stroke due to immediate occlusion of stent by plaque
protrusion.
Case report
A 24-year-old woman presented with progressive blurring
of vision, recurrent episodes of syncope and bilateral upper
limb claudication for last 1 year. There was no significant
family history. On general examination bilateral upper
limb pulse was not palpable. But, the lower limb pulses
were palpable and blood pressure (BP) recorded at lower
limb showed 160/85. On cardiovascular system examina-
tion, there was loud first heart sound and bilateral carotid
artery bruit. Neurological and other system examination
did not reveal any significant abnormality. There were
ophthalmologic features of hypertensive retinopathy. As
she was a young female and had pulselessness in bilateral
upper limb with hypertension and carotid artery bruit, TA
was diagnosed clinically in our case. Blood investigations
showed presence of anemia (hemoglobin, 10.2 gm/dl),
leucocytosis (12500/mm3) and high erythrocyte sedimen-
tation rate (ESR, 56 mm). Renal and liver function tests
showed normal results. She was on regular treatment with
oral methotrexate because she had history of steroid tox-
icity at the beginning when it was started after diagnosis of
Electronic supplementary material The online version of thisarticle (doi:10.1007/s12928-013-0176-x) contains supplementarymaterial, which is available to authorized users.
B. C. Srinivas � S. Patra (&) � B. Reddy �C. M. Nagesh � C. N. Manjunath
Department of Cardiology, Sri Jayadeva Institute
of Cardiovascular Sciences and Research,
Bangalore 560069, Karnataka, India
e-mail: [email protected]
123
Cardiovasc Interv and Ther
DOI 10.1007/s12928-013-0176-x
TA. CT aortogram and arch vessel were done which
showed significant stenosis of B/L common carotid artery
(CCA) and total occlusion of B/L subclavian artery (SCA),
but there was no evidence of high plaque burden seen.
Angiography revealed the same with right CCA 99 %, left
CCA 90 % stenosis and occlusion of other arch vessels
(Fig. 1). As our patient had progressive loss of vision, plan
was to go ahead with endovascular treatment of CCA and
as right CCA had more stenosis than left CCA, angioplasty
and stenting of right CCA were planned at first sitting. She
was pre-medicated with dual antiplatelet therapy (DAPT)
and loading dose of aspirin and clopidogrel was given on
the day before the procedure and also on the day of the
procedure. During the procedure, unfractionated heparin
(UFH) bolus (5000 units) was given at the beginning. She
was stented successfully and uneventfully by using long
7 9 120 mm smart precise cordis stent (Fig. 2). Distal
embolic protection device was not used in our case because
TA is not a disease with high plaque burden like that in
atheromatous carotid artery stenosis and she could not
afford that also. Immediately after the procedure activated
clotting time (ACT) was 290 s. During observation in post-
catheterisation word, she developed left-sided hemiparesis
within 45 min of the procedure. She was brought back to
catheterisation laboratory and check angiogram taken
which showed occlusion of the stent proximally by plaque
protrusion (Fig. 3). Cerebral angiogram of brain (Fig. 4)
was done immediately which showed embolic occlusion of
inferior division of right middle cerebral artery (MCA). For
the reason of acute stroke along with plaque protrusion
which was thought to be the reason for stroke in our
patient, she was managed immediately by intra-arterially
administered bolus of 2 lacks unit urokinase. Post-proce-
dure she had residual weakness and CT brain also showed
large infarct in the right MCA territory. She was re-stented
by a same overlapping stent (Fig. 5) as there was no
available close-cell stent in our catheterization laboratory.
But later she improved neurologically and was followed up
over the last 6 months. Now, she has good vision, no
syncope and only minimal weakness of left side of the
body (power-4?/5). She is also treated with weekly dose of
Fig. 1 Angiography revealed 99 % stenosis of right CCA and total
occlusion of right SCA
Fig. 2 Stented successfully by using long 7 9 120 mm smart precise
cordis stent
Fig. 3 Check angiogram showed occlusion of the stent proximally by
plaque protrusion
B. C. Srinivas et al.
123
oral methotrexate, folinic acid and DAPT with aspirin
(150 mg/day) and clopidogrel (75 mg/day).
Discussion
In our case, the patient presented mainly with neurological
symptoms like blurring of vision and recurrent syncopal
attack. The neurological manifestations of TA result pri-
marily from decreased blood flow caused by steno-occlu-
sive lesions in the arch and cervical arteries to the brain
and/or shifting of the blood flow (steal) [3]. Neurological
manifestations are most often associated with obstructive
lesions of multiple arch and cervical arteries, occurring
during the latest stages of disease progression which have
been reported in 57 to 80 % of patients, may include
headache, dizziness, visual disturbance or loss, stroke, and
transient ischemic attack (TIA) [3]. Management strategies
for TA include medical therapy with steroids or immuno-
suppressive agents and revascularization procedures. In
conjunction with medical treatment, PTA and/or stenting of
supra-aortic arteries in TA is feasible and durable, and
provides good symptomatic relief in patients with multiple
stenoocclusive lesions of supra-aortic arteries [4]. Stent-
supported angioplasty of a sole supraaortic artery in TA is
safe and effective and provides good symptomatic relief in
patients with multiple steno-occlusive lesions of arch
arteries like in our case [2]. Although surgical treatment
has been used to bypass the stenosed segment, the diffuse,
proximal, and multifocal involvement of the arch vessels
may make surgical revascularization difficult [3]. Endo-
vascular treatment has emerged as the initial mode of
treatment for stenosis of the aorta, renal, and subclavian
arteries caused by TA. Less is known, however, about the
role of endovascular treatment for lesions in the carotid,
brachiocephalic, and vertebral arteries [5]. Progressive loss
of vision was the reason behind to stent right CCA at the
first step in our case. Carotid artery stenting (CAS) place-
ment was shown to be a feasible option for treating long
segment stenosis of carotid arteries in patients with TA
with encouraging results [6] and in our case, we have used
long 120 mm stent. There have been some reports of re-
occlusion due to plaque protrusion after CAS for athero-
sclerotic stenosis but this is rarely seen in TA as in TA
carotid artery stenosis is mainly due to fibrotic occlusion of
vascular lumen and even though the ACT was in thera-
peutic range [6]. Restenosis rates of percutaneously treated
Takayasu lesions are high and especially diffuse lesions of
arch vessels are associated with a higher rate of restenosis
than focal lesions [7]. Though, CT angiogram didn’t reveal
any features of plaque burden, but MRI or intravascular
ultrasound (IVS) are considered as better mode of inves-
tigations for this purpose.
As our patient had acute stroke with occlusion of MCA
territory, we treated this case with intra-arterial urokinase.
At that moment, she was very sick so we did not take much
time for restenting after intra-arterial injection. Our patient
improved dramatically on the very next day which indi-
rectly suggests that our treatment with lytic therapy was
effective. It might be better if we could demonstrate one
cerebral angiogram after lysis showing effective lysis but at
that situation our primary aim was to address the plaque
and clot burden within the carotid artery which was
threatening to be embolized again by plastering them
against the vessel wall by another stent as soon as possible
and we were very much successful.
Fig. 4 Cerebral angiogram (lateral view) showed embolic occlusion
of inferior division of right MCA (black arrow)
Fig. 5 Re-stented by an overlapping stent
Stroke and reocclusion following CAS in TA
123
Because ESR at the time of admission may affect the
results of endovascular treatment, it is important to strictly
control active disease by administering immunosuppressive
agents before and after endovascular treatment [8]. Though
we had treated our case with oral methotrexate, admission
ESR was high and it might be the reason for immediate
plaque protrusion in our case as it is mandatory to control
inflammation before performing any intervention in TA.
We should keep in mind that endovascular stenting for TA
does not always keep the patency of the affected vessels,
and severity of the stenosis and/or uncontrollable systemic
inflammation could be a risk factor for restenosis. There-
fore, careful follow-up under strict control of inflammation
is mandatory. In a case of immediate stent closure by
plaque protrusion, closed-cell design stent seems to be
preferable for stenting as what we should do in our case.
But, in our catheterization laboratory, there was no avail-
ability of closed-cell design stent. Novel approaches are
being sought to treat restenosis in these patients, such as
the use of stent grafts [9]. Though reopening a chronically
occluded carotid artery also risks an embolic shower to the
brain, immediate post-procedural stroke due to occlusion of
stent by plaque protrusion is unknown. Using multiple sites
of arterial access, distal embolic protection devices can be
deployed in both the vertebral and internal carotid arteries
to reduce the risk of stroke [10] what we did not use in our
case.
Conclusion
Endovascular treatment with stenting with a long stent is
feasible in maintaining patency of carotid artery in TA.
Before percutaneous intervention, disease activity should
be controlled. Distal embolic protection should be used if
feasible in these cases. We should observe carefully during
post-procedural period for the development of complica-
tion (stroke, etc.) like in our case and if it is so, then it can
be managed successfully by administering immediate intra-
arterial fibrinolytic therapy followed by an overlapping
stenting of carotid artery and especially by a stent which
has closed-cell design.
Conflict of interest None.
References
1. Spacek M, Zimolova P, Veselka J. Takayasu arteritis: use of
drug-eluting stent and balloon to treat recurring carotid resteno-
sis. J Invasive Cardiol. 2012;24(9):E190–2.
2. Tyagi S, Gupta MD, Singh P, Shrimal D, Girish MP. Percuta-
neous revascularization of sole arch artery for severe cerebral
ischemia resulting from Takayasu arteritis. J Vasc Interv Radiol.
2008;19(12):1699–703.
3. Kim HJ, Lee CS, Kim JS, Know SU, et al. Outcomes after en-
dovascular treatment of symptomatic patients with Takayasu’s
arteritis. Interv Neuroradiol. 2011;17(2):252–60.
4. Angiletta D, Marinazzo D, Guido G, Fullone M, Pulli R, Regina
G. Eight-year follow-up of endovascular repair of a brachioce-
phalic trunk aneurysm due to Takayasu’s arteritis. J Vasc Surg.
2012;56(2):504–7.
5. Lee BB, Laredo J, Neville R, Villavicencio JL. Endovascular
management of Takayasu arteritis: is it a durable option? Vas-
cular. 2009;17(3):138–46.
6. Hu J, Huang H, Zhang X, Li G, et al. Stent placement for
treatment of long segment (C80 mm) carotid artery stenosis in
patients with Takayasu disease. J Vasc Interv Radiol. 2012;
23(11):1473–7.
7. Us M, Numan F, Goksel OS, Basaran M, Yilmaz AT. Stenting for
stenosing Takayasu aortitis following carotid artery stenosis in a
32-year-old patient. Vascular. 2008;16(5):283–6.
8. Horie N, Hayashi K, Morikawa M, So G, et al. Restenosis after
endovascular PTA/stenting for supra-aortic branches in Takayasu
aortitis: report of three cases and review of the literature. Acta
Neurochir (Wien). 2011;153(5):1135–9.
9. Tann SM, Pershad A. A novel approach to the treatment of
recurrent non-atherosclerotic carotid stenosis in a patient with
Takayasu arteritis. Catheter Cardiovasc Interv. 2012;80(2):
337–41.
10. Stiefel MF, Park MS, McDougall CG, Albuquerque FC. Endo-
vascular treatment of innominate artery occlusion with simulta-
neous vertebral and carotid artery distal protection: case report.
Neurosurgery. 2010;66(4):E843–4.
B. C. Srinivas et al.
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