1. 72° CONGRESSO NAZIONALE http://www2.sicardiologia.it/wsc2011/eabstract/html/919.htm
72° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 10 – 12 dicembre 2011
urgent percutaneous right carotid revascularization in a patient with left internal carotid artery
agenesis and impending ischemic stroke
Elisabetta Ricottini (a), Rosetta Melfi (a), Silvia Caroli (a), Andrea D'Ambrosio (a), Annunziata Nusca
(a), Vincenzo Vizzi (a), Marco Miglionico (a), Rocco Contuzzi (a), Domenico Grieco (a), Giuseppe Patti
(a), Germano Di Sciascio (a)
(a) Department of Cardiovascular Sciences, Campus Bio-Medico University, Rome
Background. Agenesis of internal carotid artery (ICA) is a rare congenital anomaly occurring <0,01% of
the population, with a left side predominance. Blood supply of the affected side is compensated through
the circle of Willis, vertebrobasilar system or contralateral ICA (with enlargment of normally existing
segments) and presence of an abnormal or fetal arteries. Treatment of patients affected by agenesis of
ICA with contralateral stenosis, is still controversial. We reported a case of a man with a left ICA
agenesis, affected by heart failure, who need urgent carotid revascularization for subsequently multiple
transient ischemic attacks.
Case report. A 78 years old-male patient with left ventricular dysfunction was admitted to our
observation for chest pain, dyspnea and signs of acute heart failure. Coronary angiography revealed
diffuse multivessel disease not amenable to complete revascularization by coronary bypass and EKG
monitoring revealed frequent ventricular tachycardia. An AICD was successfully implanted. 72 hours
after the procedure, during hospitalization, the patient developed multiple episodes of cognitive
impairment and aphasia. He had not history of previous neurological impairment or stroke. Carotid
Doppler Ultrasound and Transcranial Ultrasound showed the agenesis or occlusion at the origin of the
left ICA with severe stenosis of right ICA and severe stenosis of the left middle cerebral artery. An
angio-CT scan was performed which revealed the absence of petrus carotid canal on the left side,
pathognomonic sign of agenesis of the carotid artery. Surgery was contraindicated for the absence of
contralateral compensation and comorbidities. Since the patient continued to had recurrent transient
ischemic attacks, we decided to perform an urgent percutaneous right carotid revascularization, with the
releasing of a self-expanding nitinol stent without predilatation, avoiding any blood flow interruption.
Complete restore of neurological status was observed and the patient was discharged in double
anti-platelet therapy.
Conclusion. In the setting of patients with carotid stenosis, controlateral occlusion/agenesis and acute,
transient neurological symptoms, timing of treatment are still controversial and revascularization is at
very high risk. Adequate controlateral compensation is crucial. In our case, urgent percutaneous carotid
angioplasty with self-expanding stent was safe and successful, allowing a very short time of carotid
occlusion.
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