Demographics82-year-old Hispanic female with asymptomatic moderate right carotid artery stenosis who underwent elective transfemoral right carotid artery stent (TF-CAS) with her cardiologist. HistoryDuring right TF-CAS, angioplasty was performed using a 6-mm balloon. Subsequent angiogram demonstrated extravasation from the carotid bulb with associated enlarging hematoma, requiring temporary balloon occlusion and intubation for airway protection as a stent-graft was obtained. A 6-mm x 25-mm Viabahn stent was requested, however a 6-mm x 250-mm stent-graft was advanced and deployed, inadvertently. Post-deployment, the stent extended from the mid-internal carotid artery, through the innominate artery, and across the aortic arch into the descending thoracic aorta. Five days post-procedure, she experienced alterations in mental status with associated weakness, leading to a stroke evaluation and MRI that demonstrated infarcts in multiple vascular distributions raising concern for the stent-graft across her arch as the central embolic source. PlanA decision was made to proceed with explant of the proximal segment of the stent-graft. The common carotid artery (CCA) was exposed from the level of the clavicle to the carotid bifurcation via an incision anterior to the sternocleidomastoid. Ice-cold saline was placed in the field around the CCA to reverse the thermal memory of the nitinol stent-graft, increasing pliability and allowing easier removal of the proximal segment. After several cycles of saline-instillation, systemic heparinization was given, and a clamp was applied proximal to the CCA bifurcation. A transverse arteriotomy was made on the right CCA, with care to avoid injury to the stent fabric. The stent was then freed from the posterior wall and the proximal 20 cm were removed without resistance and transected. The posterior wall of the stent was secured to the CCA with tacking sutures. The arteriotomy was secured with a running prolene suture after flushing and removing all debris proximally and distally. The platysma and skin were approximated. Upon awakening, the patient was mentating appropriately and neurologically intact. She was later discharged to a rehabilitation facility. DiscussionTransfemoral carotid artery stenting remains a viable alternative to carotid endarterectomy and transcarotid carotid artery revascularization, when done safely for the correct indications. We demonstrate the safe extraction of an oversized stent-graft using adjuncts such as instillation of ice-cold saline to reverse the nitinol stent’s thermal memory.
