PREOPERATIVE DIAGNOSIS: Right internal carotid artery stenosis, symptomatic.
POSTOPERATIVE DIAGNOSIS: Right internal carotid artery stenosis, symptomatic.
OPERATION: Carotid angiogram with right internal carotid artery stenting.
SURGEON: John Doe, MD
ANESTHESIA: Local
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the interventional radiology suite, where he was placed in a supine position for carotid angiogram with right internal carotid artery stenting. Monitors were placed, and he was monitored during the entire procedure by registered nurse and the attending physician. He also was given Plavix 75 mg orally prior to the procedure and a local anesthetic was used. The patient’s right groin was then prepped and sterilely draped. Lidocaine 1% was used as the local anesthetic. His right common femoral artery was punctured, and under direct fluoroscopic guidance, a wire was advanced into the aorta. The iliac arteries were very tortuous, but the wire was able to pass through the tortuosity.
A 5 French sheath was placed into the right groin and then a pigtail catheter was placed over the wire into the ascending aorta. In a 30-degree LAO position, an aortic arch angiogram was performed identifying the branches of the arch. Heparin 5000 units was given at this time. Later in the procedure, another 2500 units were given for a total of 7500 units of heparin. The right innominate artery was cannulated using a Simmons catheter. There was a great deal of tortuosity within the innominate artery as well, but the tortuosity was able to be managed, and a wire was advanced into the common carotid artery. An exchange was performed for a super-stiff Amplatz wire, and over this wire, a 6-French shuttle sheath was advanced into the common carotid artery.
Angiograms were performed, which identified a high grade, very ulcerated stenosis in the proximal right internal carotid artery. The decision was made to proceed with stenting. At this point, a 6.5 mm Accunet distal embolic protection device was chosen. It was passed through the lesion into the distal intracranial internal carotid artery and deployed in the usual fashion. The decision was made not to predilate the lesion and a 7 mm to 10 mm tapered 4 cm length stent was chosen. It was placed over the wire into the lesion and deployed. Atropine 0.5 mg was given at this time for some bradycardia.
Post-placement images revealed minimal residual stenosis and no postdilatation was performed. The basket was recaptured using a capture device and the wires were removed. An Angio-Seal was used to close the right groin and this was done without any complication. The patient tolerated the procedure well and was transferred to the intensive care unit postoperatively.
