Symptomatic High-grade Stenosis Research Articles

156 Stenting of Intracranial Stenosis With a Fibrin-heparin Coated Stent Multicentre Experience

INTRODUCTION: Mechanical thrombectomy (MT) has become the standard treatment for acute ischemic stroke due to large vessel occlusions (LVO). However, in up to 30% MT may not result in successful recanalization due to an underlying stenosis or clot recalcitrant to retrieval. Bail-out stenting has been reported to be a treatment option to achieve permanent recanalization. METHODS: We retrospectively analysed data from 16 stroke centres. Patients treated with the CREDO heal Stent were divided into two groups: symptomatic high-grade intracranial stenosis (sICAD group) and persisting LVO due to underlying stenosis after at least one mechanical thrombectomy attempt (Rescue Stenting group). Primary endpoints were the improvement of stenosis grade and the rate of successful recanalization after stenting defined as mTICI = 2b for the sICAD and the Rescue Stenting group respectively. Favourable neurological outcome was defined by modified Rankin Score (mRS) at 90 days. RESULTS: 121 patients were treated from 2021-2023 with the CREDO heal Stent. Rescue stenting and sICAD treatment was performed in 82 and 39 cases respectively. Overall, a final TICI = 2b score was achieved in 94.5%. In 14% periprocedural complications occurred were in-stent thrombosis accounted for 6.3% (rescue stenting group). The mean stenosis grade in the sICAD group was 90% before and 15% after PTA and stenting. On follow-up (n = 27) restenosis was observed in 2.8%. CONCLUSIONS: The CREDO® heal stent offers a new treatment option for patients with sICAD or with persistent occlusion during thrombectomy procedures. The final mTICI sore is in accordance with uncoated devices. The rate of restenosis is low compared to previous trials. Its effectiveness with regard to long-term ischemic complications has to be evaluated in the prospective ReCHRUT trial.

Long-term outcomes of carotid stenting in a single neurovascular center: up to 12-year retrospective analysis with a focus on the influence of comorbidities.

The aim of this study was to evaluate long-term outcomes in patients who underwent carotid artery stenting (CAS) for symptomatic or asymptomatic high-grade stenosis. A total of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522) underwent CAS at our center between 2009 and 2020. A total of 560 patients or contacts (asymptomatic, n = 316; symptomatic, n = 244) were interviewed by telephone to evaluate long-term outcomes with a mean follow-up of 5 years. Mortality from all causes, myocardial infarction, and stroke, as well as comorbidities influencing their occurrence, including overall survival and stroke-free survival, were examined. The overall survival rate for all-cause mortality was 91.6% at 1 year, 77.1% at 5 years, and 55.7% at 10 years. A total of 39 (6.9%) patients had an ischemic stroke during long-term follow-up. The stroke-free survival rates at 1 year, 5 years, and 10 years were 97.9%, 92.7%, and 86.6%, respectively. Stroke-free survival and overall survival did not differ significantly between the symptomatic and asymptomatic groups (overall survival, p = 0.304; stroke-free survival, p = 0.336). Regular physical activity reduced the risk of stroke and death and was associated with better long-term clinical outcomes. Age at treatment and diabetes mellitus were statistically significantly associated with death during follow-up. Long-term follow-up data confirmed the effectiveness and durability of CAS as a therapy option for both symptomatic and asymptomatic patients. In patient selection for CAS, special consideration should be paid to patient age, ability to engage in physical activity, and diabetes mellitus.

Use of transcarotid artery revascularization for mechanical thrombectomy and treatment of symptomatic high-grade carotid artery stenosis associated with free-floating thrombus: illustrative case.

BACKGROUNDPatients with symptomatic high-grade stenosis of the internal carotid artery (ICA) associated with a free-floating thrombus (FFT) present a significant clinical challenge. In general, for patients with moderate to severe symptomatic ICA stenosis, carotid revascularization is recommended within 2 weeks of symptom onset; however, some physicians suggest that revascularization should be delayed in cases with FFT because some data suggest that early surgery with carotid endarterectomy or carotid stent poses a higher risk for stroke. Likewise, delayed revascularization with anticoagulation may increase risk of recurrent stroke. Few reports on the management of FTT included the use of a transcarotid artery revascularization (TCAR) approach for carotid revascularization with mechanical aspiration thrombectomy.OBSERVATIONSThis report described the use of TCAR for direct mechanical thrombectomy and carotid stent placement for a patient with 80% right ICA stenosis along with a large FFT extending into the bulb and the external carotid artery.LESSONSThe TCAR approach for mechanical thrombectomy and carotid stenting is a safe alternative for early revascularization with low periprocedural stroke risks.

Drug-Coated Balloons for the Treatment of Symptomatic Intracranial High-Grade Stenosis: A Review of the Current Rationale.

Symptomatic intracranial atherosclerotic disease (sICAD) remains a challenging disorder in the neurovascular field. Despite best medical treatment, the recurrence rate for stroke remains high in patients with intracranial high-grade stenosis (>70–99%). Furthermore, two large randomized trials (SAMMPRIS and VISSIT) failed to prove the efficacy of percutaneous transluminal angioplasty and stenting in patients with sICAD. Drug-coated balloon percutaneous transluminal angioplasty (DCB-PTA) represents an alternative treatment modality with therapeutic benefits for interventional cardiology. However, there are very few articles in the existing literature that relate to the use of DCB-PTA in sICAD patients. Here, we aimed to review the rationale underlying the use of DCB-PTA in sICAD patients and summarize recent developments in the neurovascular field.

Performance of the Edwards Sapien 3 Ultra Transcatheter Aortic Valve System in Patients With Aortic Stenosis and Annulus Diameter in Proximity to Valve Size.

The new Sapien 3 Ultra (S3U) transcatheter heart valve (Edwards Lifesciences) was designed with the intention to improve paravalvular sealing. In patients with an annulus size in proximity to the prosthesis size, little or no oversizing of the transcatheter aortic valve implantation (TAVI) prosthesis may lead to paravalvular regurgitation. Thus, this study was designed to assess valve performance in such patients. We retrospectively enrolled 30 consecutive patients with symptomatic high-grade aortic stenosis scheduled for transfemoral TAVI between October 2019 and May 2020. Comprehensive computed tomography angiography for TAVI planning included standard measurements and quantification of calcification of the aortic valve. All patients had an aortic annular size in proximity to the valve size (maximum <15%) and received an S3U valve. Before discharge, paravalvular leakage was assessed via transthoracic echocardiography with an operator blinded to the TAVI results. In addition, 30-day outcome was assessed. The S3U was implanted in all patients without any procedural complications. One patient received a 20 mm S3U valve, 18 received 23 mm S3U valves, and 11 received 26 mm S3U valves; the annular sizes were 19.7 mm, 22.9 ± 0.2 mm, and 25.8 ± 0.2 mm, respectively. Quantification of calcification of the aortic valve revealed significant calcifications with a median Agatston score of 2571 AU (interquartile range, 1685-3467 AU). Postprocedural transthoracic echocardiography showed an excellent result in all but 2 patients. In the latter, aortic insufficiency grade I was seen. Thirty-day survival was 96.7%. The new S3U valve shows excellent performance in patients with high-grade aortic stenosis and annular size in proximity to the valve size, even in presence of significant valvular calcification.

Reader response: Lower carotid revascularization rates after stroke in racial/ethnic minority-serving US hospitals.

I read the article by Faigle et al.1 about the overall low rates of revascularization for symptomatic carotid stenosis in all groups of patients. Even under the best scenario of whites in a predominantly white-serving hospital, the predicted rates were <25% (table 3),1 suggesting a broad underutilization of this procedure nationwide and even more so in underserved hospitals and groups in the population. Our local practice includes carotid endarterectomy (CEA)/carotid artery stenting (CAS) in all high-grade symptomatic patients within 3 days after an infarct, unless the stroke is major and disabling or the patient refuses. With this in mind, and because rates were so low in this case series, methodologic issues in the study may exist. There likely is misclassification of patients as having symptomatic high-grade internal carotid artery (ICA) stenosis that requires intervention by using International Classification of Diseases, Ninth Revision, Clinical Modification codes 433.11 and 433.31 only—the validity of this code for high-grade symptomatic stenosis was not described, and this would also have been helpful information for codes on CEA/CAS. These codes likely include low-grade stenosis, which can be used by coders to justify 433.xx, as well as potentially intracranial ICA stenosis, for which revascularization is not indicated, and are more likely to be present in nonwhites. The probability of misclassification of mild stenosis or of intracranial artery stenosis (patients who should not be undergoing revascularization; more likely nonwhite), as CEA/CAS candidates, is a likely source of bias and could explain the results. Whites are also more likely to undergo CEA/CAS if asymptomatic,2 potentially due to socioeconomic factors, and the 433.xx has been used for asymptomatic patients to justify treatment or after developing a postoperative stroke.3 Last, patients who were transferred were excluded, but the reason for transfer was not explored; if they had symptomatic disease that needed surgery, they were indeed treated appropriately by the hospital that was otherwise low performing.

Endovascular therapy of symptomatic high-grade stenosis of left internal carotid artery in C6 segment using Elutax "3" Neuro pDEB.

Endovascular therapy of symptomatic high-grade stenosis of left internal carotid artery in C6 segment using Elutax "3" Neuro pDEB.

Long-term outcomes of open and endovascular treatment of recurrent carotid artery stenosis – a 16-year retrospective single centre case series

Background: The aim of this study is to evaluate perioperative as well as long-term outcomes in patients operated with carotid endarterectomy (CEA) or stenting (CAS) due to symptomatic or asymptomatic high-grade restenosis of the internal carotid artery (ICA). Patients and methods: In a retrospective analysis of our electronic database including 2980 patients who underwent carotid endarterectomy or stenting due to a symptomatic or asymptomatic high-grade stenosis of the ICA, between 2000 and 2016, we enrolled 111 patients with recurrent ICA stenosis. Results: An ipsilateral 2nd time restenosis (>80% in the asymptomatic and >50% in the symptomatic patients according to NASCET criteria) of ICA was detected in 13 patients (12%); 3 of them were symptomatic. These patients were managed with either CEA (n=5/38%) or CAS (n=8/62%) with no perioperative stroke or death. The stroke-free survival rates at 2 and 8years for CEA were 98% and 98% versus 100% and 100% for CAS respectively (P=.271). The type of the initial procedure (patch, CAS or interposition) did not play any significant role for the development of a 2nd time restenosis (P=.841). Conclusions: Redo-CEA/CAS seem to have similar results as primary procedures (as reported in the literature) with favorable periprocedural and long-term outcomes.

Predictors of cognitive functioning after carotid revascularization

PurposeHigh-grade carotid stenosis can affect cognition, but the relationship between stenosis correction and cognitive outcome is not fully understood, yet. The aim of this study was to evaluate the predictors of post-operative neurocognitive functioning in patients with symptomatic severe internal carotid artery (ICA) stenosis undergoing carotid endarterectomy (CEA). Materials and methodsPatients with history of transient ischemic attack within the past 6 months and ipsilateral high-grade stenosis of ICA undergoing CEA were prospectively enrolled. Cerebral hemodynamics was assessed by means of the cerebral vasomotor reactivity (CVR) to hypercapnia measured through transcranial Doppler ultrasonography. Coloured Progressive Matrices plus Complex Figure Copy Test, and phonemic plus categorical (ca) Verbal Fluency tests were performed to assess right and left hemisphere cognitive functions, respectively. Cerebral hemodynamics and cognitive functions were assessed before and 6 months after CEA. ResultsOne hundred and eighty-one patients were included. The mean age was 73.2 (6.9) years and 121 (66.9%) were males. At 6 months from CEA, the scores obtained in the cognitive tests exploring the re-vascularized hemisphere's functions and ipsilateral cerebral hemodynamics were improved. At multivariate linear regression analysis, the 6-month change in cognitive performance was inversely associated with age [ß = −0.17, 95% confidence interval (CI) −0.22 to −0.12; p < .001] and CVR value obtained before CEA on the side of ICA stenosis (ß = −6.25, 95% CI −7.40 to −5.10; p < .001). ConclusionsIn patients with symptomatic high-grade ICA stenosis, age and cerebral hemodynamic status before CEA predicted the neurocognitive performance changes after surgical stenosis correction.

Cerebrovascular reactivity recovery following carotid angioplasty and stenting

BackgroundInternal carotid artery high-grade stenosis is a major cause of stroke. Carotid angioplasty and stenting (CAS) is a reasonable approach for treatment of certain patients. Cerebrovascular reactivity (CVR) evaluated through breath holding index test can assess the outcome following CAS.AimEvaluate changes in CVR before and after CAS.Subjects and methodThirty-two patients with 35 symptomatic internal carotid artery high-grade stenosis (> 70%) were enrolled by the mean of ultrasound screening. Breath holding index test was done using transcranial Doppler ultrasound before and after CAS.ResultsThe study includes 32 patients (22 males and 10 females). The mean age was 61.91 ± 6.59 years. The main risk factor was hypertension (75.3%). All patients showed an increase in mean flow velocity and BHI following CAS (P < 0.001) on both ipsilateral and contralateral side. Both groups (70–90% and > 90% stenosis) showed similar improvement of CVR.ConclusionCAS improves CVR in all high grades of internal carotid artery stenosis.

Medium-term results of undersized angioplasty and stenting for symptomatic high-grade intracranial atherosclerotic stenosis with Enterprise.

The aim of this retrospective study is to evaluate medium-term results of undersized balloon angioplasty and stenting for symptomatic high-grade (70-99%) stenosis of a major intracranial artery with Enterprise stent. This study included 68 consecutive symptomatic (recurrent transient ischemic attack (TIA) or ischemic stroke under dual antiplatelet treatment) patients with high-grade (70-99%) stenosis of a major intracranial artery who were endovascularly treated with undersized balloon angioplasty and Enterprise stent deployment between July 2012 and December 2017. Primary outcomes were any stroke or death within 30 days after procedure. Secondary outcomes were technical success rates, stroke and restenosis during the follow-up period. A total of 68 lesions in 68 patients (mean age: 62 ± 7 years) were treated with a technical success rate of 99%. The degree of pre-procedural stenosis was 92 ± 6% and dropped to 12 ± 10% after stent deployment. No patient developed any stroke or death during the periprocedural period. Intracranial hemorrhage was observed in 1 (1.5%) patient. In 60 (88%) patients with available imaging follow-up in-stent restenosis was observed in 2 patients. Mean follow-up period was 22 ± 17 months (range 6-72) and none of the patients experienced recurrent TIA or stroke during the follow-up period. In this retrospective single-center study undersized balloon angioplasty and deployment of a self-expandable stent with relatively low radial force was safe and effective for endovascular treatment of high-grade intracranial arterial stenosis with high technical success rate, low periprocedural complication rates and favorable medium-term follow-up results.

Percutaneous Antegrade and Retrograde Endovascular approach to Symptomatic High-Grade Subclavian Artery Stenosis: Technique and Follow-Up.

Background and Purpose:Angioplasty and stenting of the subclavian artery have been reported with high technical and clinical success rates, low complication rates, and good midterm patency rates. Different antegrade or retrograde endovascular catheter-based approaches are used. Nowadays, endovascular therapy has taken over open surgical techniques in subclavian artery disease. The purpose of this study was to determine safety, efficacy, and midterm clinical and radiological outcome of the endovascular treatment with special focus on the different technical approaches in subclavian artery disease.Materials and Methods:Between 2014 and 2017, 11 patients (10 men, 1 woman) with symptomatic high-grade stenosis (90%–100%) of the subclavian artery were treated with endovascular treatment. Their mean age was 51.3 years (range, 32-61 years). Mean angiographic and clinical follow-up was 22.5 months (range, 5-44 months). Clinical follow-up was performed at hospital discharge and routine follow-up was performed at 1, 3, 12 months, and 6 monthly thereafter. In all 11 patients, a percutaneous approach was used successfully. In eight patients, the lesions were accessed retrogradely through a brachial artery puncture.Results:Acute success rate was 100%. There were no significant peri-procedure complications. At the latest clinical follow-up (mean of 22.5 months), all patients showed a good outcome with a restenosis rate of 18.2% including a patient with Takayasu arteritis.Conclusion:Percutaneous antegrade and retrograde stenting of high-grade subclavian artery stenosis is a viable less invasive alternative to open bypass surgery with good midterm clinical results and patency rates.

Neuro Elutax SV drug-eluting balloon versus Wingspan stent system in symptomatic intracranial high-grade stenosis: a single-center experience

BackgroundIntracranial atherosclerotic disease is a well-known cause of ischemic stroke. Following the SAMMPRIS trial, medical treatment is favored over stenting. Drug-eluting balloons (DEB) are widely used in coronary angioplasty, showing...

Stroke prevention-surgical and interventional approaches to carotid stenosis

Extra cranial carotid artery stenosis is an important cause of stroke, which often needs treatment with carotid revascularization. To prevent stroke recurrence, carotid endarterectomy (CEA) has been well-established for several decades for symptomatic high and moderate grade stenosis. Carotid stenting is a less invasive alternative to CEA and several recent trials have compared the efficacy of the 2 procedures in patients with carotid stenosis. Carotid artery stenting has emerged as a potential mode of therapy for high surgical risk patients with symptomatic high-grade stenosis. This review focuses on the current data available that will enable the clinician to decide optimal treatment strategies for patients with carotid stenosis.

Abstract 19: Multicenter Prospective Trial of Intracranial Stent Placement in Patients With Symptomatic High-grade Intracranial Stenosis

Purpose: Based on the results of SAMMPRIS trial, modifications in patient selection and procedural aspects for intracranial stent placement have been recommended. We performed a multicenter prospective single arm trial to determine if such modifications will result in lower rates of peri-procedural stroke and/or death. Materials and Methods: The study enrolled patients with recent transient ischemic attack or ischemic stroke (excluding lacunar ischemic events) related to high-grade (70-99% in severity) stenosis of a major intracranial artery. Patients were treated using angioplasty and self-expanding stent after 3 weeks of index ischemic event at one of the 10 high volume centers in China. An independent neurologist ascertained the occurrence of any stroke and/or death within one month after the procedure. Results: A total of 100 consecutive patients were recruited. The target lesions were located in middle cerebral artery [M1] (n=38, 38%), intracranial internal carotid artery (n=17, 17%), intradural vertebral artery (n=18, 18%), and basilar artery (n=27, 27%). The technical success rate of stent deployment with residual stenosis &lt;50% was 100%. The overall one-month stroke and/or death rate was 2% (95% confidence interval 0.7% - 4.7%). Two ischemic strokes occurred in pontine region (perforator distribution) in patients following angioplasty and stent placement for basilar artery stenosis. Conclusion: The results of this prospective multi-center study demonstrated that modifications in patient selection and procedural aspects can substantially reduce the one-month stroke and/or death rate following intracranial stent placement.

Asymptomatic dissecting intimal lesions of common carotid arteries after carotid endarterectomy.

Carotid endarterectomy is a standard treatment for symptomatic high-degree internal carotid artery stenosis. The aim of this article is to present possible intimal lesions after carotid endarterectomy. These lesions could be manifested as intimal flaps, intimal steps or dissections with or without occlusion or stenosis of the artery. The evaluation of the frequency and characteristics of the asymptomatic dissecting intimal lesions of the common carotid arteries was performed in a sample of 100 patients who underwent endarterectomy for symptomatic high-grade stenosis of the internal carotid artery. We found five patients with asymptomatic dissecting intimal lesions of the common carotid arteries. The most common causes of these intimal lesions were shunting and prolongation of the clamping time. Routine carotid ultrasound follow-up exams are necessary because of the potential need for a change in the antithrombotic therapy or due to a need to perform an endovascular treatment.

Safety and efficacy of the treatment for symptomatic atherosclerotic high-grade stenosis in middle cerebral artery with Wingspan stent

Objective To assess the safety and efficacy of the treatment for symptomatic atherosclerotic high-grade stenosis in middle cerebral artery with Wingspan stent.Methods The medical records of Wingspan stenting for 102 cases with symptomatic middle cerebral artery high-grade stenosis from February 2008 to May 2012 in our hospital were reviewed retrospectively.All of the patients suffered from ischemic stroke or transient ischemic attack ( TIA ) attributed to the atherosclerotic high-grade stenosis in middle cerebral artery and the stenosis of 70%to 99%was confirmed by DSA before the stenting procedure.All the stroke, death, TIA within 30 days after the stenting procedure or during the follow-up beyond 30 days were observed and recorded.In-stent restenosis were recorded after DSA or CTA was performed 6 months later.χ2 test or Fisher exact test was used to compare in-stent restenosis rate among patients with different clinical and pathological conditions.Results Stenting procedure were successfully performed in 100 patients (98.0%,100/102).The mean degree of stenosis was reduced from (81.0 ±8.4)% to (15.3 ±6.7)%right after surgery.Eight adverse cardiovascular events (7.8 %, 8/102) occured within 30 days ,including seven stroke or death ( 6.9%, 7/102 ) and 1 TIA.The mean clinical follow-up duration was ( 29 ± 15) months in 82 patients, and 9 ischemic events were documented (4 cases of ipsilateral recurrent stroke , 3 cases of ipsilateral TIA, and 2 cases of contralateral ischemic stroke ).The mean radiological follow-up duration was (11 ±9) months in 55 patients.Among them, 8 patients (14.3%) had in-stent restenosis and 3 patients had symptomatic restenosis.The restenosis rate in patients with age ≤49 years.(25.0%,7/28) was higher than those with age >49 years ( 3.7%,1/27 ) ( P>0.05 ).The restenosis rate in patients with lesion size>7.5 mm(25.0%,7/28) was higher than those with lesion size ≤7.5 mm (3.7%,1/27)(P>0.05).Conclusions The treatment of symptomatic middle cerebral artery high-grade stenosis with Wingspan system was relatively safe and associated with a low perioperative complication rate.The long-term efficacy of the treatment for symptomatic atherosclerotic high-grade stenosis in middle cerebral artery with Wingspan stent is prominent. Key words: Atherosclerosis ; Middle cerebral artery ; Stent ; Radiology,interventional ;

Edwards Sapien XT valve placement as treatment option for aortic regurgitation after transfemoral CoreValve implantation: a multicenter experience

Transcatheter aortic valve replacement (TAVI), though a preferred treatment option in the elderly population carrying increased risks for open heart surgery, may result in prognosis-limiting moderate or severe aortic regurgitation. Here, we report a series of 11 patients from 3 German TAVI centers, suffering from moderate- to high-grade aortic regurgitation after CoreValve implantation, who were subsequently treated by Edwards Sapien XT implantation. The patients were 79.5 ± 4.2 years of age and presented between November 2009 and February 2013 with a symptomatic high-grade aortic stenosis (mean maximum gradient 57 ± 22 mmHg) and EuroSCORE of 16 ± 7%. Initial implantation of a Medtronic CoreValve resulted in moderate-to-severe aortic regurgitation (grade 2.64 ± 0.37) although postdilatation was attempted in eight cases and snare repositioning was attempted in one case. All 11 patients were treated by a Sapien XT (Edwards) valve implanted into the initially deployed CoreValve: four via transfemoral, one via transaortical and six via transapical approaches. Successful implantation was possible in all 11 patients resulting in a reduction of aortic regurgitation to mean grade 0.23 ± 0.39. Two patients required permanent pacemaker. After 30 days, ten patients were alive, whereas one patient succumbed to pneumonia complicating advanced chronic obstructive pulmonary disease. In the instance of moderate or severe aortic regurgitation after TAVI of a CoreValve, transfemoral or transapical Sapien XT valve-in-valve deployment is an excellent option to reduce residual regurgitation to none or mild.

Safety and feasibility of transcatheter aortic valve implantation in patients with severe persistent thrombocytopenia

Untreated symptomatic high-grade aortic stenosis remains a lethal disease. Therefore, a comprehensive evaluation is necessary to obtain the best individual treatment for each patient. Recently, transcatheter aortic valve implantation (TAVI) was developed as an innovative therapy for high-risk and inoperable patients. Persistent thrombocytopenia is an established risk for conventional open heart surgery, but is not covered by traditional surgical risk scores. The aim of the study was the investigation of safety and feasibility of TAVI in patients with severe thrombocytopenia. Because of the complicated outcome of patients with persistent thrombocytopenia undergoing heart surgery, we considered all patients with high-grade aortic stenosis and a thrombocyte count of less than 100 per nl as surgical high-risk patients. Out of these high-risk surgical patients, six patients with symptomatic high-grade aortic stenosis and severe thrombocytopenia were deemed to be TAVI candidates and underwent TAVI procedures in 2010 and 2011 (transfemoral: n = 4; transapical: n = 2) at the University Hospital of Frankfurt. The outcome of these patients was analyzed prospectively in order to document safety and feasibility of TAVI in such patients. All TAVI procedures were performed successfully with excellent functional results. There was no occurrence of major or minor bleeding complications, acute renal failure or nosocomial infection. One patient died of an ischemic stroke 12 days after the procedure. The five remaining patients were alive at the 12-month follow-up without relevant cardiovascular events and excellent valve performance. TAVI is an effective and well tolerated method to treat patients with chronic persistent thrombocytopenia and symptomatic high-grade aortic stenosis, and therefore a reasonable alternative to conventional heart surgery in such patients. The indication for TAVI in patients with thrombocytopenia and symptomatic high-grade aortic stenosis might be generated independently from conventional scoring systems.

Absent right common carotid artery with stenting of symptomatic internal carotid artery stenosis

Absent common carotid artery with independent origin of internal and external carotid arteries from the subclavian artery is a rare but recognized phenomenon. We describe one such case with an associated symptomatic proximal high-grade stenosis of the right internal carotid artery. The abnormal carotid anatomy was not initially well appreciated, resulting in a failed surgical exploration and subsequent successful endovascular carotid stenting. To our knowledge, this is the first reported case of carotid stent in a right internal carotid artery originating from the subclavian artery.