Subtotal Karotis Arter Darlığının Distal Korumasız Perkutan Tedavisi
Özet
Bu vaka sunumunda, akut iskemik inme tanısıyla takip edilen, 89 yaşında, diyabetik ve koroner arter hastalığı öyküsü olan bir kadın hastanın başarılı perkutan tedavisi ele alınmaktadır. Bilgisayarlı tomografik (BT) karotis anjiyografisinde sol internal karotis arterde (İCA) %90, sağ İCA'da ise %99 subtotal darlık saptanmıştır. İleri yaş ve anestezi riskleri nedeniyle hastaya bilateral ayrı seanslarda karotis arter stentleme (KAS) yapılması kararlaştırılmıştır. Sol İCA'ya distal emboli koruyucu filtre kullanılarak müdahale edilmiş, ancak anatominin aşırı kıvrımlı ve açılı olması nedeniyle filtrenin geçişi sırasında sağ İCA'da plak embolisi riski öngörülmüştür. Bu nedenle, sağ İCA lezyonuna distal koruyucu filtre kullanılmadan, floopy tel üzerinden balon predilatasyonu ve kapalı hücreli stent implantasyonu uygulanmıştır. İşlem optimal düzeyde başarıyla tamamlanmış ve hasta sorunsuz taburcu edilmiştir. Karotis arter stentlemesinde filtre kullanımı yaygın olsa da, ileri yaşa bağlı tortuyosite ve subtotal lezyon varlığı gibi zorlu anatomik durumlarda filtre geçişinin diseksiyon, vasospazm veya plak embolisi gibi periprosedürel komplikasyon risklerini artırabildiği görülmüştür. Sonuç olarak, bu tür seçilmiş yüksek riskli vakalarda, periprosedürel komplikasyonları önlemek amacıyla distal koruma filtresi kullanılmaksızın kapalı hücre stent teknolojisi ile yapılan KAS prosedürünün daha güvenli bir alternatif olabileceği gösterilmiştir.
This case report presents the successful percutaneous treatment of an 89-year-old female patient with diabetes and coronary artery disease, followed up with a diagnosis of acute ischemic stroke. Computed tomographic (CT) carotid angiography revealed 90% stenosis in the left internal carotid artery (ICA) and 99% subtotal stenosis in the right ICA. Due to advanced age and high anesthesia risks, bilateral carotid artery stenting (CAS) in separate sessions was planned. While the left ICA was treated under a distal embolic protection filter, the highly tortuous and angulated anatomy raised concerns that the filter shaft passage could trigger distal plaque embolism in the right ICA. Therefore, the right ICA lesion was successfully treated without a distal embolic protection filter, using a floppy wire for balloon predilation and implanting a closed-cell self-expanding stent. The procedure achieved near-complete patency with optimal success, and the patient was discharged without complications. Although embolic filters are standard in CAS, challenging anatomical variations such as age-related tortuosity and subtotal stenosis increase periprocedural risks, including dissection, vasospasm, and plaque mobilization during filter deployment. Consequently, this case demonstrates that in selected high-risk patients, CAS performed without a distal protection filter leveraging closed-cell stent technology can serve as a safer alternative to minimize periprocedural complications.
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