The expected benefit of this treatment is dependent on long-term anatomical results. Restenosis after carotid endarterectomy (CEA) is an indication for CAS when the 30-day perioperative rate of stroke and death is less than 3%. Endovascular treatment provides an advantage in that it reduces the risk of cranial nerve injury. The short-term results of these studies have revealed that there is no significant difference between the two treatments. Many studies have compared CAS to redo surgery. Because the use of stents has extensively evolved and cerebral protection systems are frequently used, carotid angioplasty/stenting (CAS) has become an alternative method for treating carotid restenosis. The development of endovascular techniques has considerably changed the indications for vascular surgery. In literature, the incidence of cranial nerve injuries has been reported to range from 1% to 17%, and studies show that most such reported injuries are transient. Redo carotid surgery is technically difficult and usually complicated by cranial nerve injury. Surgery was the standard treatment for restenosis for many years, and the 30-day periprocedural stroke and death rate is lower than 3% in asymptomatic patients. Patient was discharged home with NIHSS of 3.The incidence of restenosis after carotid surgery varies from 1% to 36%, depending on the definition of restenosis and the length of follow-up. No residual dissection, spasm or thrombus noted. Delayed angiographic runs continued to demonstrate full patency of the ICA lumen (Figure1‐D). The SR wire was then separated from the SR and fully retracted outside the body (Figure1‐C). A gradual pulling pressure was applied to the SR wire while maintaining adjacent microwire access and fully inflated Viatrac 5mm x 30 mm extracranial balloon over the entangled portion to ensure continuous vascular access (Figure1‐B). We decided to attempt safe separation of the SR from its pusher wire and leave behind the patent ICA stent/SR in place. Surgical bailout with emergent carotid endarterectomy and removal of the stent/SR metal mesh was considered.3,4 However, given the high surgical risk with recent intravenous load of antithrombotics for emergent stent placement, this option was deemed as a last resort. The cervical ICA lumen remained patent without evidence of dissection or residual thrombus however, the presence of SR pusher‐wire would preclude safe termination of the procedure. Numerous attempts to disentangle the SR from the ICA stent including attempts to re‐sheath the SR with different size microcatheters and guide catheters were unsuccessful. Large thrombus was recovered from the AC aspirate. Upon retrieving the clot‐incorporated SR with the intention to fully retrieve the SR into the locally placed aspiration catheter (AC) in the supraclinoid ICA under continuous aspiration, the triaxial system collapsed into the distal CCA, likely due to the mid cervical ICA loop, leading to entanglement of the proximal end of SR and distal ICA stent (Figure1‐A). A stable triaxial system was navigated through the stented cervical ICA. An antegrade revascularization approach was then pursued with uneventful cervical ICA angioplasty followed by extracranial carotid closed cell Xact stent placement. Following our retrograde revascularization approach, an intracranial pass using an embotrap 5mm x 37 mm stent retriever (SR) was attempted however given proximal cervical ICA tortuosity and underlying proximal stenosis, the stability of triaxial system prevented optimal placement of the SR and achieving intracranial reperfusion. EVT was pursued, initial angiographic run of the left common carotid artery demonstrated severe stenosis at the origin of left cervical ICA which harbors a mid‐cervical ICA loop and proximal left MCA occlusion. This is a case report of a 73‐year‐old woman who presented with left MCA syndrome‐NIHSS 13 found to have left ICA/MCA tandem occlusions. Stroke: Vascular and Interventional Neurology.Journal of the American Heart Association (JAHA).Circ: Cardiovascular Quality & Outcomes.Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB).
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