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Carotid Endarterectomy Remains A Feasible Bailout For Progressive Disease After TCAR: A Case Report
Aidin Baghbani, M.D., Blaz Podgorsek, MD, Jason B. Storch, MD, Gordon H. Martin, MD, Naveed U. Saqib, MD, Daniel G. Miles, MD.
University of Texas Health Science Center at Houston, Houston, TX, USA.
DEMOGRAPHICS: A 67-year-old male with a history of atrial fibrillation, coronary artery disease, diabetes mellitus, hyperlipidemia, hypertension, and peripheral vascular disease.
HISTORY: His surgical history included mediastinal mass excision, aortobifemoral bypass, multiple lower extremity revascularizations, and bilateral transcarotid artery revascularizations (TCARs)—right-sided 14 months earlier and left-sided 11 months prior. Surveillance duplex ultrasound (DUS) initially showed normal velocities and waveforms with a right interanal carotid artery (ICA) peak systolic velocity (PSV) of 108cm/s. Serial studies demonstrated progressive velocity elevation, reaching PSV 389cm/s with an ICA-to-common carotid artery (CCA) ratio of 6.4. The mid and proximal ICA contained heterogeneous calcified plaque, consistent with >80% restenosis. Although neurologically asymptomatic, hemodynamically significant restenosis with blunted distal waveforms prompted operative management.
PLAN: The patient underwent right carotid endarterectomy (CEA) with stent explantation with continuous SSEP and MEP neuromonitoring. A longitudinal arteriotomy revealed progression of native plaque compressing the stent lumen. The previously placed ENROUTE stent was identified extending from distal CCA to proximal ICA. The stent and plaque were carefully mobilized and removed en bloc, without requiring incision of the stent itself. Endarterectomy was extended into healthy mid-ICA, and bovine pericardial patch closure was performed. The technical conduct mirrored routine CEA, and explantation was not unusually difficult. The patient tolerated the procedure well and was discharged on postoperative day one neurologically intact.
DISCUSSION: Restenosis following carotid artery stenting occurs in 2-20% of cases, typically within 12-18 months. Management strategies include balloon angioplasty, repeat stenting, or drug-eluting devices, but these may be less effective in heavily calcified or progressively stenotic lesions. CEA with stent explantation provides definitive therapy and has been reported primarily after transfemoral stenting. To our knowledge, this is the first report of ENROUTE TCAR stent explantation. Notably, the stent was not firmly incorporated into the arterial wall, permitting straightforward removal en bloc. This case highlights CEA with stent removal as a feasible, safe salvage strategy for severe restenosis after TCAR, warranting further reporting and study.
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