FA

Male patient 56 years old, he is diabetic and hypertensive with previous history of ischemic heart disease that was treated with multiple percutaneous coronary intervention (PCI), the patient experienced an attack of transient ischemic attack (TIA) three weeks ago.

carotid doppler was done and revealed right internal carotid artery stenosis with systolic flow velocity of 300cm/sec, that was confirmed by a computational tomography (CT)scan.

The patient was discussed at our heart team meeting and percutaneous carotid artery stenting was advised given the high cardiovascular risk for the carotid artery endarterectomy.

Right radial access waschosen with regular 6 fr sheath, a guiding catheter XB 3.5 was introduced tothe aortic arch, then guide wire withdrawn to allow the catheter to bend onitself with slight rotation we directed the catheter tip toward thebrachiocephalic trunk then a Terumo stiff 300 cm wire was advanced toward the CCA,with the help of road map the wire was advanced to good distal portion of the ECA.Then the guiding catheterand the sheath was withdrawn and exchanged with a 6 fr long sheath 90 cm boughtto the CCA.A floppy wire was usedinto distal ICA, followed by spider FX filter wire advancement and placeddistal to the ICA lesion, a Portege Rx carotid stent was advanced and placedfollowed by post dilation with 5.0x20 mm balloon.One hour later, thepatient started to complain with neck pain at the site of intervention, and weobserved a small supraclavicular soft swelling. Ultra sound (U/S) was done andrevealed a fluid collection around the sternomastoid muscle with nocontinuation with the CCA (Figure 2 A).We returned to review theangiograms again and we discovered a small perforation at a small branch of theECA (Figure 1). As the patient was stable and this small hematoma was notaffecting his respiration we decided for conservative management and closefollow upAfter 4 hours the US confirmed that hematoma is not increasing. Afterone week, US confirmed complete resolution of hematoma and patient wascompletely asymptomatic (Figure 2 B). 

Usage of stiff Treumo wires in carotid intervention showed be used with extreme caution and under strict maneuvers to reduce the perforation possibilities and may be replaced with atraumatic tip wires that may provide more safety to the procedures.Even if perforation happens US availability and operator's familiarity with rapid scanning is crucial to help complication definitions and diagnosis, also small hematomas can be conservatively managed and followed up and reserve coiling for large branches and large hematomas, but coiling materials should always be available and ready to use.