Advanced vasospasm in carotid stenting using the distal filter-type embolic protection device: A case report

Abstract

There are difficulties in the use of embolic protection devices (EPD) for carotid artery stenting (CAS), and various side effects can be observed. We presented a patient who underwent CAS with a distal filter-type (DF) EPD for symptomatic right internal carotid artery (ICA) stenosis and showed advanced vasospasm. A 68-year-old male patient was hospitalized with a pre-diagnosis of transient ischemic attack (TIA) in the form of left-sided weakness. Computed tomography angiography revealed 90% stenosis in the right ICA. On the 5th day, he underwent an angiography, which showed a plaque causing 90% stenosis. A 5F Spider FX (Medtronic Corp.; Minneapolis, MN, USA) was placed in the cervical ICA. At this time, mild vasospasm was observed in the cervical ICA, but the flow was normal. After pre-dilatation, a Protégé 8-6x40 stent was placed in the stenotic segment. Due to the 50% residual stenosis, a post-dilatation was performed. After post-dilatation, advanced vasospasm developed distal to the stent and the flow was completely obstructed. Vasospasm significantly regressed within a few minutes with intra-arterial nitrate administration. There was no change in the neurological examination of the patient during and after the procedure. Although vasospasm is usually a self-limiting complication that resolves without clinical symptoms, it may cause a TIA or an infarct. In CAS procedures, the possibility of a vasospasm should be kept in mind and if it occurs, the irritant should be removed. If there is no improvement, an intra-arterial vasodilator should be administered.