Proximal Left Internal Carotid Artery Research Articles

Focal finger palsy and wrist pain due to cortical infarction: a case report

Abstract Background Hand knob infarction induced focal weakness of contralateral hand or distal arm, only accounts for less than 1% of all ischemic strokes. To date, there is no case with pain during sleep as the onset symptoms being reported. The atypical symptoms of hand knob infarction might increase the risk of delaying treatment especially in the hyperacute phase of stroke. Case presentation A 70-year-old man awoke from sleep due to sudden pain of his right medial wrist and presented to the emergency department with difficulty extending his right index and middle fingers within the time window of intravenous thrombolysis. But the intravenous thrombolysis was not given based on the NIHSS score (0) and atypical symptoms. MRI showed multiple DWI hyperintense lesions, including partial left hand knob area and left posterior central gyrus. CTA showed a severe focal stenosis of proximal left internal carotid artery. Conclusions The hand knob infarction might onset with unusual pain and should be carefully inspected in patients combined with acute onset of focal hand paresis.

Abstract 14484: Shockwave Lithotripsy as a Non Surgical Modality for Calcified Carotid Stenosis

An 80-year-old gentleman with significant bilateral carotid artery stenosis and previous right carotid endarterectomy underwent a CT Angiogram of the Head and Neck due to multiple episodes of syncope. The study revealed heavily calcified atherosclerotic disease at the left carotid bulb and bifurcation, causing high-grade luminal stenosis of 80 to 82% at the origin of the internal carotid artery. Hence, a decision was made to obtain a cerebral angiogram. Aortic arch angiogram revealed a type III arch, following which a cerebral catheter wire was engaged in the left carotid artery. A selective angiogram showed 80% calcified stenosis at the level of bifurcation, with the left external carotid artery being 100% occluded. Given the heavily calcified lesion, supra core guidewire was crossed across the lesion, followed by advancement of protection device into the distal segment of the left internal carotid artery. Balloon angioplasty was performed twice from the ostial to the proximal segment of the left internal carotid artery. An attempt was made to place a stent without any success. Subsequently, a decision was made to proceed with shockwave lithoplasty. We inserted a transvenous pacemaker with a backup rate of 40 bpm. A Shockwave catheter was inserted and shockwaves were delivered with multiple inflation techniques at 4 atmospheric pressure for 15 seconds each. Periodic neuro assessments were normal. This was followed by the placement of stents in the distal left common carotid and ostial to proximal left internal carotid artery reducing the calcified 80% stenosed lesion to 10% with excellent angiographic results. Subsequently, the filter and the catheter were removed and the femoral artery access site was secured. The patient tolerated the procedure very well without any immediate or delayed complications. The intracerebral vasculature remained intact as confirmed by a cerebral angiogram. TVP was removed and the patient was discharged in a stable condition after 2 days. Hence, Shockwave lithotripsy can be successfully used for critical carotid artery stenosis in patients that pose a high surgical risk. It helps soften the lesion for better dilatation of the vessel and achieve improved luminal gain for appropriate stent expansion.

Management of Mobile Thrombus With Distal Protection Devices During Carotid Artery Angioplasty: 2-Dimensional Operative Video.

Embolic protection devices (EPDs) have become a standard of care during internal carotid artery revascularization.1,2 This video is about a 57-yr-old-male who presented with a wake-up stroke with a left hemispheric syndrome. Head computed tomography angiography (CTA) revealed tandem occlusions of the proximal left internal carotid artery (ICA) and of the distal left middle cerebral artery (MCA) with an ASPECT (Alberta Stroke Program Early CTScore) score of 6. The patient underwent a cerebral angiogram and was treated with balloon angioplasty with a distal EPD and mechanical thrombectomy. The EPD became occluded with thrombus from the ICA and was retrieved through a 6-Fr Sofia (MicroVention) under continuous aspiration. Successful revascularization of the proximal ICA and distal MCA was achieved. No procedure-related complications occurred, and the patient's neurological exam improved. Tandem occlusions can occur in up to 15% of strokes. The optimal treatment can be controversial, but mechanical thrombectomy and ICA revascularization with a distal EPD appear to be safe and effective in selected patients.3 Consent was obtained for the procedure and for the video production.

Visual Vignette

Case Presentation: A 40-year-old woman with primary hyperparathyroidism (pHPT) and unlocalized disease (negative neck ultrasonography and sestamibi scan) underwent neck exploration. Two borderline appearing inferior parathyroid glands were removed and a normal right superior gland was left in situ while the left superior gland was not identified. The removed parathyroid glands were of increased weight and histologically showed borderline hyperplasia. However, the postoperative calcium remained raised at over 3.0 mmol/L (2.2 to 2.6 mmol/L). A subsequent, 4-dimensional (4D) computed tomography (CT) scan failed to identify the parathyroid adenoma. Parathyroid angiography and venous sampling demonstrated no vascular blush, but significant elevation of parathyroid hormone (PTH) within the veins draining the left side of the neck. Extensive re-exploration of the left neck failed to identify a parathyroid gland and no drop in intraoperative PTH occurred after a left hemithyroidectomy. Repeated venous sampling was consistent with the source of PTH being within the left superior neck. Fluorine F 18-fluorocholine (FCH)-positive emission tomography (PET)/CT was undertaken and showed intense tracer uptake in a soft tissue focus (6 × 11 mm) lying within the carotid sheath just lateral to the proximal left internal carotid artery and medial to the internal jugular vein (Fig. 1). What is the diagnosis?

COCAINE-INDUCED THROMBOTIC STORM

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cocaine is associated with a wide array of complications through a number of different mechanisms. Although majority of cocaine related morbidity has been attributed to complications in arterial vasculature, the deleterious impact of venous complications appears to be largely unrepresented in current literature as well as clinical practice despite emerging evidence of the high prevalence and annual incidence of DVT in illicit drug users CASE PRESENTATION: 27-year-old previously healthy male presented to the ED with new onset difficulty speaking and facial droop hours after using cocaine. He was afebrile with vitals 98.5 °F, BP 142/97, HR 94 and RR 16. Examination was remarkable for expressive aphasia and right facial droop with no other focal neurological finding. CT scan of head showed thrombosed left MCA with infarct in left frontal lobe and basal ganglia. Labs were significant for a troponin of 14 md/dl and CK-MB 34. CBC and metabolic panel were unremarkable. Urine toxicology was positive for cocaine and opiates. EKG showed T wave inversion with ST depression in V1-V4 II and aVF. CTA of chest revealed bilateral segmental and subsegmental PE without any acute pulmonary disease. CTA of head and neck showed complete abrupt occlusion of proximal left internal carotid artery with distal reconstitution at the segment M1 of MCA and an intraluminal thrombus in the M1 segment. A doppler of lower extremities revealed deep venous thrombosis in left peroneal and posterior tibial veins. An ECHO failed to reveal an intracardiac shunt precluding the possibility of paradoxical thrombosis. He was continued on heparin for 10 days before being switched to Xarelto. He experienced improvement in word finding ability and is currently in rehab. Hypercoagulability work-up including prothrombin gene mutation, factor V Leiden deficiency, APLA and anti-thrombin deficiency was negative. DISCUSSION: This case illustrates an uncharacteristic presentation of cocaine-related widespread thrombotic cascade involving both arterial and venous circulations causing significant morbidity. The complex pathophysiology of widespread prothrombotic state caused by cocaine includes endothelial damage promoting increase of fibrinogen and Von Willebrand factor to platelet aggregation and clot formation. It is important to identify the impact cocaine induced venous thrombosis can mount, especially in the form of potentially fatal complications like pulmonary embolism. CONCLUSIONS: Although recent studies have focused on increased incidence and prevalence of venous thrombosis in setting of cocaine abuse, ours is the first case of documented pulmonary embolism caused by cocaine related venous thrombosis. Further studies are needed to identify patients at higher risk for this complication like rare thrombotic disorders Reference #1: 1. Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Reference #2: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (formerly the Office of Applied Studies). The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD, December 28, 2010. Reference #3: . Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Drug Abuse Warning Network: Detailed Tables: National Estimates, Drug-Related Emergency Department Visits for 2004–2009. Rockville, MD, December 28, 2010. DISCLOSURES: no disclosure on file for Erika Cappelluti; No relevant relationships by Manish Kumar, source=Web Response No relevant relationships by Alain Rizkallah, source=Web Response No relevant relationships by Nihar Shah, source=Web Response No relevant relationships by Toishi Sharma, source=Web Response

SUDDEN DYSPHASIA IN A YOUNG MAN WHO COUGHED.

A healthy 19-year-old man with no risk factors presented with focal neurological symptoms (dysphasia and right hemiparesis) in the setting of an acute febrile illness and severe cough. Initial CTs showed pan-sinusitis and pulmonary infiltrates. The cerebrospinal fluid was normal. Human coronavirus OC43 was identified in nasal swabs. Repeat CTA/MRA revealed multiple infarcts in the territory of the left middle cerebral artery (MCA) and proximal intra-luminal left internal carotid artery filling defects due to thrombi were demonstrated. No thrombophilia was found and there are no reports of sinusitis-associated carotid thrombosis in the literature. Recent infection, in particular respiratory infection is a confirmed risk factor of ischemic stroke (IS) in adults and intriguingly, also in young patients. Myriad mechanisms have been demonstrated or postulated in the very young and our report suggests adding carotid thrombi. Previously described cough-induced carotid dissection could not be demonstrated, but similarly, cough-induced intimal injury of the carotid artery remains the most likely culprit, precipitating local thrombus formation and embolization.

SUDDEN DYSPHASIA IN A YOUNG MAN WHO COUGHED

A healthy 19-year-old man with no risk factors presented with focal neurological symptoms (dysphasia and right hemiparesis) in the setting of an acute febrile illness and severe cough. Initial CTs showed pan-sinusitis and pulmonary infiltrates. The cerebrospinal fluid was normal. Human coronavirus OC43 was identified in nasal swabs. Repeat CTA/MRA revealed multiple infarcts in the territory of the left middle cerebral artery (MCA) and proximal intra-luminal left internal carotid artery filling defects due to thrombi were demonstrated. No thrombophilia was found and there are no reports of sinusitis-associated carotid thrombosis in the literature. Recent infection, in particular respiratory infection is a confirmed risk factor of ischemic stroke (IS) in adults and intriguingly, also in young patients. Myriad mechanisms have been demonstrated or postulated in the very young and our report suggests adding carotid thrombi. Previously described cough-induced carotid dissection could not be demonstrated, but similarly, cough-induced intimal injury of the carotid artery remains the most likely culprit, precipitating local thrombus formation and embolization.

Hemodynamic hemichorea associated with severe stenosis of internal carotid artery

Hemichorea refers to forcible, flowing, involuntary arrhythmic movements on one side of the body. Impaired cerebral perfusion due to internal carotid artery (ICA) stenosis would be a rare cause of hemichorea. We report a patient with hemichorea which was associated with severe stenosis of contralateral ICA. A 61 year old man with multiple myeloma admitted to hematologic department because of febrile sense. At admission, he reported involuntary movement of right hemibody which begun one day ago. Moreover, he had experienced several times of recurrent right side transient motor weakness within last month. As the presence of neck bruit in the left carotid bifurcation, brain MRI with angiography was performed. The MR angiography showed severe stenosis of left proximal ICA. Carotid duplex sonography showed 93% stenosis of left proximal ICA with elevated velocity (782 cm/sec). We prescribed massive hydration with administration of aspirin 300mg and clopidogrel 300mg. Hemichorea was subsided with the treatment. With the finding of decreased vasomotor reactivity in TCD breath holding test, we planned revascularization of the severe carotid stenosis. Carotid artery stenting was successful for the symptomatic carotid stenosis and there was no recurrent hemichorea. Hemichorea is an unusual presentation of extracranial ICA stenosis. In our patient, massive hydration and administration of antiplatelet agent resolved hemichorea, implicating cerebral hypoperfuison was the cause of the hemichorea.

Aberrant Extracranial Branch Prevents Internal Carotid Artery Occlusion

The internal carotid artery (ICA) is a terminal vessel that does not give rise to branches in the extracranial segment. The ICA occlusion typically extends to the first intracranial branch, the ophthalmic artery. We present a rare case of isolated ICA occlusion with distal patency due to an aberrant extracranial branch. A 52-year-old man with longstanding tobacco use, hypertension, hyperlipidemia, diabetes, and extensive coronary artery disease was referred to the vascular laboratory for evaluation of carotid disease. The patient had no history of transient ischemic attack (TIA), amaurosis fugax, or cerebrovascular accident. Carotid duplex results prompted further evaluation by computed tomography angiography (CTA). Duplex imaging demonstrated right common carotid artery (CCA) plaque with significantly elevated velocities and turbulent flow extending into the ICA. Mild heterogeneous plaque was noted proximally in the left ICA followed by less than 2-cm occlusion and reconstitution of flow in the distal extracranial segment. The CTA testing revealed a moderate right CCA stenosis, mild proximal left ICA plaque and an isolated occlusion of the mid-ICA and distal reconstitution via an aberrant collateral branch. The left intracranial ICA segment remained patent throughout its course but was of smaller caliber. Aberrant branches of the extracranial ICA are unusual and rarely identified by carotid duplex analysis. Awareness of this anomaly underscores the importance of determining patency of distal ICA flow in the presence of an occluded proximal segment; aberrant collaterals can make surgical exploration and endarterectomy in these patients feasible.

Stroke Associated with Left Ventricular Noncompaction in Osteogenesis Imperfecta

Osteogenesis Imperfecta (OI) is an autosomal inherited disorder characterized by blue sclera, hyperexcitable ligaments, fragile bones, deafness and teeth malformations. A 36-year-old man with undiagnosed OI was admitted to hospital with acute onset speech disorder, left sided hemiparesis and hemihypoesthesia. Magnetic Resonance Imaging (MRI) showed acute infarction on the right middle cerebral artery (MCA) territory. Transesophageal echocardiography (TEE) revealed left ventricular noncompaction (LVNC). Right MCA occlusion, stenosis of the proximal left internal carotid artery (ICA), vertebrobasilar contour irregularities were observed in MR angiography. Ischemic and hemorrhagic vascular events may be observed in disease course since Type 1 collagen is the key structural composition of the vessel wall. Furthermore, ventricular noncompaction is a special cardiomyopathy which has gained increasing attention and might cause ischemic cerebrovascular diseases. The purpose of presenting this case is the fact that OI with LVNC is a rare clinical entity in the etiology of cerebrovascular disorders in young adults.

T94. Stable “Crossover” TcMEP with post-op weakness in CEA

Introduction Carotid endarterectomies can be performed in patients with carotid artery stenosis in order to prevent future strokes. Electroencephalogram and somatosensory evoked potentials are intraoperative neuromonitoring modalities used to provide the surgeon with real-time feedback in detecting decreases in cerebral blood flow during carotid artery clamping. This may help the surgeon decide whether to shunt the carotid artery, which has potential complications. Transcranial motor evoked potentials have been used as an adjunct to EEG and SSEPs to monitor carotid endarterectomies, with Malcharek et al. reporting 0.4% false-negative TcMEPs in a review of 264 patients. We report a case where TcMEPs remain unchanged with unilateral SSEP changes that was associated with new post-operative deficits. Methods This is a case report of a 54 year old female with multiple vascular risk factors and a prior stroke three months prior with trace right upper (RUE) and lower (RLE) weakness. She presented with acute worsening of weakness and numbness, due to severe narrowing of the proximal left internal carotid artery. She underwent left carotid endarterectomy for symptomatic carotid stenosis. Three-channel EEG, SSEP with stimulation at the median nerve and posterior tibial nerve, and TcMEPs of the upper and lower extremities were setup for intraoperative neuromonitoring. The patient was anesthetized with propofol and fentanyl. Results Baseline SSEPs in all four extremities were adequate. TcMEPs were reproducible in all four extremities, except the left foot had variable responses. Of note, there were TcMEP responses ipsilateral to the hemisphere of stimulation. Seventy minutes post-incision, EEG showed burst suppression and the surgeons clamped the left carotid artery. Two minutes post-clamping, the right sided SSEP began to decrease in amplitude. The RUE and RLE SSEPs became absent at 10 min and 19 min post-clamping, respectively. TcMEPs run after the SSEPs changes were unchanged from baseline and the surgeons moved forward without shunting. At 42 min post-clamping, surgeons completed the CEA and removed the clamp. The RLE SSEP returned 3 min after unclamping, and the RUE SSEP 29 min after unclamping. The RLE SEP improved to baseline, but the RUE SEP amplitude remained significantly diminished. Left sided SSEPs were stable and bilateral TcMEPs remained unchanged throughout the entire surgery. EEG demonstrated burst suppression without any notable asymmetry. Pre-operative exam showed RUE drift and 4+/5 strength on RLE. Post-operative exam revealed flaccid RUE. Her RLE motor strength was anti-gravity, but she did not follow commands for individual muscle groups. Conclusion TcMEPs may be an unreliable measure of the nervous system when crossover responses are present in the limbs ipsilateral to the hemisphere of stimulation. In this left CEA, right-sided SSEP changes correctly heralded potential injury immediately after clamping, while right-sided TcMEPs remained unchanged.

Delayed Cerebral Hyperperfusion Syndrome after Carotid Artery Stenting: the Finding of Multimodal MRI

A 78-year-old right handed man with hypertension presented with sudden onset dysarthria and right hemiparesis. Magnetic resonance angiography revealed near-occlusion of left proximal internal carotid artery. Emergent carotid stenting was performed. On the 17th day after carotid stenting, he showed decreased consciousness. Magnetic resonance imaging (MRI) showed edematous change with high signal and increased perfusion in the left hemisphere. Our case shows that delayed cerebral hyperperfusion syndrome can occur even 2 weeks after carotid artery stenting and multimodal MRI can help accurate diagnosis. Key Words: Delayed cerebral hyperperfusion syndrome, Carotid artery stenting, Carotid artery stenosis

A lotus root-like appearance in carotid stenosis on optical coherence tomography

An 82-year-old man visited the outpatient clinic of our stroke centre because of dizziness. He had a previous history of stroke without definite sequelae. Severe stenosis in the left proximal...

Carotid stent infection: a rare but potentially fatal complication of carotid artery stenting

Infections involving endovascular devices are rare and, to our knowledge, only three cases of infection with an inserted carotid stent have ever been reported. A 68-year-old man underwent carotid artery...

Choroid artery occlusion after treatment of ICA termination aneurysm: was it caused by stent induced vasospasm?

Dear Sirs: Endovascular occlusion has become the main treatment for cerebral aneurysms in the last decade. This development was much facilitated by the ISAT trial [1] for ruptured aneurysms, but coiling, stenting and flow diversion are now also widely used for unruptured cases. While endovascular treatment is usually less invasive than surgical aneurysm clipping, coil occlusion of an aneurysm seems less durable. This has led to the increasing use of stents to reconstruct the vessel wall for the prevention of recurrences. If an elective stent placement is performed under appropriate antiplatelet medication, stentrelated complications such as thrombotic stent occlusion and embolic events are infrequent [2, 3]. We report on a rare complication after placement of a selfexpanding endovascular stent, leading to a disabling stroke in a young patient with an unruptured internal carotid artery (ICA) aneurysm. A 27-year-old female patient, who had delivered a healthy daughter 6 weeks previously, presented to her local hospital with transient left-sided weakness. Vascular risk factors included obesity (BMI=35 kg/m) and smoking. A probable transient ischaemic attack (TIA) was diagnosed, and the patient was investigated accordingly. While no obvious aetiologywas found for the TIA, her brain imaging had shown an incidental lesion, which was suggestive of a left ICA aneurysm with a diameter of around 10 mm. A subsequent CT angiogram (CTA) done at the local neurosciences centre confirmed the presence of a broad-based left ICA termination aneurysm with a maximum diameter of 12 mm, mostly extending on to the left M1 segment, but also slightly affecting the A1. No other aneurysm was seen. Given the size of the aneurysm, the patient was offered endovascular treatment. She was quoted a risk of permanent neurological deficit of 3 % or less. Because of the large neck size, a stent-assisted coil embolisation was planned, and the patient was asked to take 75 mg of aspirin and clopidogrel each starting 5 days before the planned procedure. The patient was admitted on the morning of the intervention and clerked by the clinical team. She confirmed having taken her dual antiplatelet therapy as prescribed. She also stated that she was only smoking occasionally, but her frequent absences from the ward suggested higher nicotine consumption on that morning. The procedure was performed under general anaesthetic (GA). However, bronchospasm and a sudden severe drop in blood saturation levels complicated the induction of the anaesthesia. The patient had no background of respiratory problems, and according to the anaesthetist, heavy smoking prior to the GAwas the most likely explanation. A diagnostic angiogram after intubation confirmed the presence of a large left carotid terminus aneurysm (Fig. 1a). No other abnormalities were seen. The patient received IV heparin under ACT monitoring (>250 s), but platelet function inhibition was not tested. Over an exchange wire, a 6-F 90-cm Terumo Destination sheath was placed into the left proximal ICA, and a Fargomax distal access catheter was advanced into the petrous segment of the ICA. This was complicated by vasospasm at the tip of the long sheath, and therefore, 2 mg of nimodipine was added to the saline flush. W. Kuker (*) Department of Neuroradiology, West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK e-mail: wilhelm.kuker@ndcn.ox.ac.uk

Prolonged hypotension following elective stenting of an internal carotid artery stenosis

We report a case of a 72-year-old man who had undergone elective stenting of an asymptomatic high grade stenosis of the proximal left internal carotid artery. The indication was progression...

“Isolated Carotid Bifurcation” and Vertebral-Carotid Artery Bypass for Common Carotid Artery Occlusion

Symptomatic common carotid artery (CCA) occlusion is relatively rare, and requires an elaborate vascular reconstruction procedure with which many neurosurgeons are unfamiliar. We describe a case of CCA occlusion managed by vertebral artery (VA)-internal carotid artery (ICA) saphenous vein interposition graft. An 80-year-old man presented with deterioration of consciousness, transient aphasia, and severe right hemiparesis. Angiography revealed proximal occlusion of the left CCA with concomitant patent ICA. Cerebral blood flow measurement using iodine-123 N-isopropyl-p-iodoamphetamine and single photon emission computed tomography showed corresponding hemodynamic insufficiency of the left hemisphere. The patient underwent a novel revascularization procedure, in which the saphenous vein was used as an interposition graft between the V3 segment of the VA and the left proximal ICA. Postoperative course was uneventful, and patency of the bypass graft was confirmed. VA-ICA bypass with interposition graft is an alternative treatment option for symptomatic proximal CCA occlusion.

A misplaced and entrapped pulmonary artery catheter

A misplaced and entrapped pulmonary artery catheter

Captured Macro-embolus of Fractured Atheromatous Plaque by the Embolic Protection Device during Carotid Stent Assisted Angioplasty

The authors present a case in which macro-embolus from the ruptured atheromatous plaque developed during carotid artery stenting (CAS). A 63-year-old man who had suffered a left middle cerebral artery territory infarction had significant proximal left internal carotid artery stenosis required CAS procedure. Immediate after stent deployment, the patient showed abrupt neurological deterioration with 12 × 3 mm sized macro-embolus which was caught by the embolus protection device (EPD). Retrieval of the macro-embolus was performed safely and the patient recovered to pre-procedure status. Macro-embolus can be resulted during the CAS. The EPD can capture the macro-embolus and safe removal is technically feasible.

Drug-Eluting Balloon Angioplasty for Carotid In-Stent Restenosis

To report midterm results of 3 cases in which drug-eluting balloons (DEBs) were successfully used for the management of carotid in-stent restenosis (ISR). Two women aged 68 and 70 years and a 68-year-old man were referred to our institution for asymptomatic severe stenosis [>80% with peak systolic velocity (PSV) >300 cm/s by Doppler ultrasound assessment] of individual Carotid Wallstents implanted in the proximal left internal carotid artery (ICA). In the angiosuite, the left ICA was engaged in a telescopic fashion with a triple coaxial system formed by a 6-F long sheath and a preloaded 5-F, 125-cm diagnostic catheter over a 0.035-inch soft hydrophilic guidewire. Under distal filter protection, the lesions were predilated using a 3.5 × 20-mm coronary balloon and then treated with two 1-minute inflations of a 4 × 40-mm Amphirion In.Pact paclitaxel-eluting balloon, followed by 3 months of dual antiplatelet therapy. At 12, 22, and 36 months, respectively, the patients are still asymptomatic, with duplex-documented stent patency at 6, 12, and 24 months, respectively. DEBs are an emerging strategy for carotid ISR, with encouraging midterm results in these patients. Further experience in larger cohorts is needed to confirm these preliminary observations.