Importance of Predilatation for CAS: Two Patients for Whom Balloons Were Mis-selected

Abstract

Objective: We report two patients for whom balloons for carotid artery stenting (CAS) were mis-selected, and review balloon selection for CAS and the purpose of predilatation.

Case Presentations: Case 1: A 73-year-old man developed amaurosis fugax on his right eye. An unstable, plaque-abundant stenotic lesion of the right internal carotid artery with calcification was detected. Under flow reversal, a Carotid WALLSTENT 8 mm × 29 mm was inserted, and postdilatation was performed using a Jackal 4.5 mm × 30 mm until a nominal pressure was achieved. In-stent plaque protrusion was noted. A Carotid WALLSTENT 8 mm × 21 mm was overlapped, and the procedure was completed. Subacute thrombosis (SAT) with North American Symptomatic Carotid Endarterectomy Trial (NASCET) 40% restenosis was observed 5 days after CAS. Anticoagulant therapy gradually reduced SAT.

Case 2: An 83-year-old woman presented an asymptomatic acute phase ischemic lesion in left cerebral hemisphere by scheduled MRI as a follow-up study of medical checkup. An irregular, plaque-abundant, markedly stenotic lesion of the left internal carotid artery with calcification was detected. Under flow reversal, predilatation was performed using a Sterling 3 mm × 40 mm (Boston Scientific, Marlborough, MA, USA) until a nominal pressure was achieved, and a PRECISE 9 mm × 40 mm (Cardinal Health, Inc., Dublin, OH, USA) was inserted. It was impossible to pass an Aviator 4 mm x 30 mm (Cardinal Health, Inc.) for postdilatation through the site of stenosis, and a Gateway 2.5 mm × 12 mm (Stryker, Kalamazoo, MI, USA) and Jackal 4.5 mm × 30 mm (Kaneka Medix Corp., Osaka, Japan) were used. Dilatation was achieved.

Conclusion: To improve the results of CAS, it is important to establish the purpose of balloon dilatation and select a balloon in accordance with its purpose, as indicated for the selection of embolic protection devices (EPDs) and stents.