LHY

Thisis a 69-year-old woman had medical history of peripheral arterial diseasestatus post percutaneous transluminal angioplasty to right common iliac artery,left common femoral artery, left popliteal artery, and innominate artery during2019 to 2020. She also had right middle cerebral artery infarction in 2019.Other underlying diseases included hypertension, dyslipidemia, diabetesmellitus, hypothyroidism, coral reef aorta, and chronic kidney disease stageIIIb.

She suffered from dizziness since June2022. The carotid doppler showed left internal carotid artery > 70%stenosis, with high flow velocity (peak systolic velocity = 317 cm/s and enddiastolic velocity = 19 cm/s). She took clopidogrel and cilostazol for years.The LDL level was 40 mg/dL with statin treatment and HbA1c was 6.0%. In thiscondition, she was admitted for carotid angiography and percutaneoustransluminal angioplasty.

- Right innominate artery: in-stent restenosis 80%- Right common carotid artery: distal stenosis 40%- Right internal carotid artery: patent- Right external carotid artery: 80% stenosis- Left common carotid artery: ostial 50% stenosis- Left  internal carotid artery: 80% stenosis * IVUS showed severe stenosis eccentric calcification- Left external carotid artery: patent- Left vertebral artery: proximal total occlusion

1.   Approached through rightfemoral artery with 8 Fr sheath.2.   Engaged JR4 to left commoncarotid artery.3.   Wired V-18 0.018’’200 cm tointernal carotid artery (ICA).4.   Deployed "EMBOSHIED NAV6EMBOLIC PROTECTION SYSTEM" to left distal ICA. It was hard to deliver theprotection device to the target site due to the tortuous vessel.5.   Delivered IVUS to left ICA. Itwas also hard to deliver IVUS, and the protection device was withdrawn duringdelivering the IVUS.6.   Performed IVUS to left ICA.Severe calcification with the narrowest lumen was localized.7.   Attempted to advance carotid stentto left ICA but failed.8.   Advanced V-18 to left ICA tochange the morphology of the tortuous vessel.9.   Exchanged to "Terumo Guidesheath TM 8F45cm Straight" to increase system support.10.   Advanced JR4 to left ICA lesionsite with 2 wire support and then delivered the stent. The stent was deliveredto the target site successfully. Removed V-18.11.   Deployed “Abbott XACT CarotidStent System 10.0 mm x 40 mm” to left ICA.12.   Performed thrombosuction overleft distal ICA. No thrombus was detected.13.   Post-dilated with Sterling 6*20balloon with 6 atm 5 sec.14.   Attempted to retrieve theprotection device, but the retrieve catheter could not be sent to left ICA.15.   Advanced V-18 again. Theretrieve catheter was delivered to left ICA and retrieved the protection devicesuccessfully.16.   The final flow was good. Weclosed the procedure.

Incarotid intervention, there is high risk of stroke in difficult devicedelivery. In our case, the difficulty caused from coral reef aorta and tortuousleft ICA. Tortuous ICA is more difficult to overcome than tortuous coronary.First, there is less support for guiding catheters from the aorta. Second,there is no vessel could be anchored. We use long sheath (Terumo Guide sheathTM 8F45cm Straight) to decrease resistance resulting from coral reef aorta anduse another wire to make tortuous ICA straight. Finally, we use these methodsto make whole system stable, and complete the procedure smoothly.