Use of Intracarotid Abciximab to treat Embolism after Carotid Artery Stenting Zeeshan Khan, MD Second Year Cardiology Fellow University of Oklahoma Health Science Center.

HISTORY & PHYSICAL EXAM: 67 year old man with history of diabetes mellitus II, hypertension and pulmonary fibrosis admitted to hospital with cellulitis. Hospital course was complicated by Non ST elevation mycoardial infarction requiring left main stenting as he was not a good candidate for coronary artery bypass grafting. Ten days after the procedure he developed left sided weakness. Examination revealed decreased strength on left side with decreased sensation.He had complete resolution of symptoms over next thirty minutes.

Relevant Test Prior to Angiography: CT scan of Brain: No signs of acute intracranial process. Carotid Duplex: -70-79 % stenosis involving the right internal carotid artery. -50-69 % stenosis involving the left internal carotid artery.

Angiography: Type I carotid arch with bovine origin of left carotid artery. Right internal carotid artery has 80% stenosis and provides right and left communicating arteries and right middle cerebral artery. Left internal carotid artery has 50 % stenosis supplying only left middle cerebral artery

Interventional Management: 6 French Destination sheath was advanced into the right common carotid artery over a Rosen wire. Bivalirudin was started for anticoagulation. Emboshield embolic protection system was deployed in the prepetrous segment of carotid. Lesion was predilated with 3 x 30 balloon and 7 x 10 mm stent was deployed. This was post dilated and filter was withdrawn.

Interventional Management: At this point patient reported weakness in left arm and leg. Another angiogram was obtained with concerns for embolisation in M3 segment. Loading dose of intracarotid Abciximab was given promptly with resolution of symptoms with in 15 minutes. He was reloaded with clopidogrel. After carotid intervention another CT scan was obtained which was unchanged.

Conclusion: Embolization is a major risk in carotid artery stenting. Prior to the use of Embolic protection devices glycoprotein IIb/IIIa inhibitors were used to prevent this but there use declined mainly due to increased risk of bleeding. Though rare, even with the use of these devices, intraprocedural thromboembolic events occur and require prompt identification and treatment with intracarotid abciximab.