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Masoud Z, Daza-Ovalle JF, Esenwa C. Importance of cerebral angiography in the evaluation of delayed carotid stent thrombosis: a case report. J Med Case Rep 2024; 18:109. [PMID: 38383477 PMCID: PMC10882745 DOI: 10.1186/s13256-024-04379-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/12/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND While noninvasive imaging is typically used during the initial assessment of carotid artery disease, digital subtraction angiography remains the gold standard for evaluating carotid stent thrombosis and stenosis (Krawisz in Cardiol Clin 39:539-549, 2021). This case highlights the importance of digital subtraction angiography for assessing carotid artery stent patency in place of non-invasive imaging. CASE PRESENTATION We present a 61-year-old African American male patient with a history of right cervical internal carotid artery dissection that was treated with carotid artery stenting and endovascular thrombectomy, who developed recurrent right hemispheric infarcts related to delayed carotid stent thrombosis. Digital subtraction angiography found multiple filling defects consistent with extensive in-stent thrombosis not clearly observed with magnetic resonance angiography. Etiology was likely secondary to chronic antiplatelet noncompliance. Therefore, the patient was treated medically with a heparin drip, and dual antiplatelet therapy (dAPT) was restarted. At 1-month follow-up the patient did not report new motor or sensory deficits. CONCLUSION In the setting of delayed carotid stent thrombosis secondary to antiplatelet noncompliance, digital subtraction angiography may play an essential diagnostic role for early identification and determination of the most appropriate treatment.
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Affiliation(s)
- Zaki Masoud
- Department of Neurology/Albert Einstein College of Medicine, The Stern Stroke Center at Montefiore Health System, 3316 Rochambeau Ave, 4th Floor, Bronx, NY, 10467, USA
| | - Juan Felipe Daza-Ovalle
- Department of Neurology/Albert Einstein College of Medicine, The Stern Stroke Center at Montefiore Health System, 3316 Rochambeau Ave, 4th Floor, Bronx, NY, 10467, USA.
| | - Charles Esenwa
- Department of Neurology/Albert Einstein College of Medicine, The Stern Stroke Center at Montefiore Health System, 3316 Rochambeau Ave, 4th Floor, Bronx, NY, 10467, USA
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Gornik H, Rundek T, Gardener H, Benenati J, Dahiya N, Hamburg N. Optimization of Duplex Velocity Criteria for Diagnosis of Internal Carotid Artery (ICA) Stenosis: A Report of the Intersocietal Accreditation Commission (IAC) Vascular Testing Division Carotid Diagnostic Criteria Committee. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gornik HL, Rundek T, Gardener H, Benenati JF, Dahiya N, Hamburg NM, Kupinski AM, Leers SA, Lilly MP, Lohr JM, Pellerito JS, Rholl KS, Vickery MA, Hutchisson MS, Needleman L. Optimization of duplex velocity criteria for diagnosis of internal carotid artery (ICA) stenosis: A report of the Intersocietal Accreditation Commission (IAC) Vascular Testing Division Carotid Diagnostic Criteria Committee. Vasc Med 2021; 26:515-525. [PMID: 34009060 PMCID: PMC8493430 DOI: 10.1177/1358863x211011253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Diagnostic criteria to classify severity of internal carotid artery (ICA) stenosis vary across vascular laboratories. Consensus-based criteria, proposed by the Society of Radiologists in Ultrasound in 2003 (SRUCC), have been broadly implemented but have not been adequately validated. We conducted a multicentered, retrospective correlative imaging study of duplex ultrasound versus catheter angiography for evaluation of severity of ICA stenosis. Velocity data were abstracted from bilateral duplex studies performed between 1/1/2009 and 12/31/2015 and studies were interpreted using SRUCC. Percentage ICA stenosis was determined using North American Symptomatic Carotid Endarterectomy Trial (NASCET) methodology. Receiver operating characteristic analysis evaluated the performance of SRUCC parameters compared with angiography. Of 448 ICA sides (from 224 patients), 299 ICA sides (from 167 patients) were included. Agreement between duplex ultrasound and angiography was moderate (κ = 0.42), with overestimation of degree of stenosis for both moderate (50–69%) and severe (⩾ 70%) ICA lesions. The primary SRUCC parameter for ⩾ 50% ICA stenosis of peak-systolic velocity (PSV) of ⩾ 125 cm/sec did not meet prespecified thresholds for adequate sensitivity, specificity, and accuracy (sensitivity 97.8%, specificity 64.2%, accuracy 74.5%). Test performance was improved by raising the PSV threshold to ⩾ 180 cm/sec (sensitivity 93.3%, specificity 81.6%, accuracy 85.2%) or by adding the additional parameter of ICA/common carotid artery (CCA) PSV ratio ⩾ 2.0 (sensitivity 94.3%, specificity 84.3%, accuracy 87.4%). For ⩾ 70% ICA stenosis, analysis was limited by a low number of cases with angiographically severe disease. Interpretation of carotid duplex examinations using SRUCC resulted in significant overestimation of severity of ICA stenosis when compared with angiography; raising the PSV threshold for ⩾ 50% ICA stenosis to ⩾ 180 cm/sec as a single parameter or requiring the ICA/CCA PSV ratio ⩾ 2.0 in addition to PSV of ⩾ 125 cm/sec for laboratories using the SRUCC is recommended to improve the accuracy of carotid duplex examinations.
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Affiliation(s)
- Heather L Gornik
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hannah Gardener
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James F Benenati
- Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | | | - Naomi M Hamburg
- Whitaker Cardiovascular Institute, Boston University, Boston, MA, USA
| | - Ann Marie Kupinski
- Albany Medical College, Albany, NY, USA.,North Country Vascular Diagnostics, Inc., Altamont, NY, USA
| | - Steven A Leers
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael P Lilly
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MA, USA
| | - Joann M Lohr
- Department of Surgery, Wm. Jennings Bryan Dorn VA Medical Center, Columbia, SC, USA
| | - John S Pellerito
- Department of Radiology, Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Kenneth S Rholl
- Department of Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, George Washington University, Alexandria, VA, USA
| | | | - Marge S Hutchisson
- Intersocietal Accreditation Commission (IAC), Vascular Testing Division, Ellicott City, MD, USA
| | - Laurence Needleman
- Department of Radiology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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