The value of 3D-CT angiographic assessment prior to carotid stenting

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The value of 3D-CT angiographic assessment prior to carotid stenting Mark C. Wyers, MD, Richard J. Powell, MD, Mark F. Fillinger, Brian W. Nolan, MD, Jack L. Cronenwett, MD Journal of Vascular Surgery Volume 49, Issue 3, Pages 614-622 (March 2009) DOI: 10.1016/j.jvs.2008.10.015 Copyright © 2009 Terms and Conditions

Fig 1 Representative anatomy that would be considered favorable for carotid artery stenting (CAS). Bloodflow is modeled red; atheromatous plaque is yellow; and calcified plaque is white. A, Simulated LAO projection of a favorable “type 1” aortic arch. B-D, Orthogonal diameter measurements of the common carotid artery (CCA), proximal and distal ICA at sites indicated in (E). E, Magnified view of a favorable bifurcation lesion with, little calcification or tortuosity. The appropriate gantry angle for best view can be calculated. F, Sagital reformat with three-dimensional reconstruction superimposed to illustrate appropriate bony landmarks and to show a simulated tapered carotid stent (green). Journal of Vascular Surgery 2009 49, 614-622DOI: (10.1016/j.jvs.2008.10.015) Copyright © 2009 Terms and Conditions

Fig 2 Vessel access problems. A, Type III aortic arch; all brachiocephalic vessels emanate from the proximal ascending aorta. This arch configuration will make stable sheath access to the distal common carotid artery (CCA) very difficult or impossible from a groin approach. B and C, A second aortic arch with a severe CCA origin stenosis. (B) is the orthogonal CTA reformatted image at the level of stenosis indicated in (C). The asterisk (*) marks the innominate artery and the < indicates the stenotic CCA origin. Journal of Vascular Surgery 2009 49, 614-622DOI: (10.1016/j.jvs.2008.10.015) Copyright © 2009 Terms and Conditions

Fig 3 Near occlusions. A, Magnified view of the carotid bifurcation with the soft plaque (yellow) made transparent. The flow channel (red) is not detectable thru the bifurcation stenosis. B, Orthogonal reformat thru the mid portion of the bifurcation stenosis confirms the lack of visible contrast within the calcified rim of the carotid bulb. ECA, External carotid artery; ICA, internal carotid artery; SCM, sternocleidomastoid muscle; CFV, common facial vein. Journal of Vascular Surgery 2009 49, 614-622DOI: (10.1016/j.jvs.2008.10.015) Copyright © 2009 Terms and Conditions

Fig 4 Extreme lesion calcification. A-C, Orthogonal reformatted CT images at proximal (A), mid (B), and distal (C) portions of the bifurcation plaque seen at the right in image (D). Calcification is nearly circumferential at each level of the lesion. Journal of Vascular Surgery 2009 49, 614-622DOI: (10.1016/j.jvs.2008.10.015) Copyright © 2009 Terms and Conditions

Fig 5 Carotid string sign. Both images are of the same patient. The noncalcified plaque (yellow) has been removed in (B) to demonstrate the diminutive flow channel as it extends all the way to the base of the skull. Journal of Vascular Surgery 2009 49, 614-622DOI: (10.1016/j.jvs.2008.10.015) Copyright © 2009 Terms and Conditions

Fig 6 Severe ICA tortuosity. A, Multiple 180 degree bends in the distal ICA will prevent safe deployment of a distal embolic protection device (EPD). B, A complete ICA loop will also complicate placement of the EPD. Placing a stent close to such a tortuous segment will also potentially result in an exacerbation of the tortuosity or create a kink. Journal of Vascular Surgery 2009 49, 614-622DOI: (10.1016/j.jvs.2008.10.015) Copyright © 2009 Terms and Conditions

Fig 7 Severe intracranial disease. 3D-CTA reconstruction of the intracranial circulation makes evaluation of the intracranial ICA that may be instrumented by guidewires or by distal embolic protection device (EPD) devices. Further evaluation of the collaterals from the contralateral side or posterior circulation is provided by evaluation of the circle of Willis. Anterior (A) and posterior (B) views show heavy disease of the carotid siphon and absent posterior communicating arteries in this patient. Journal of Vascular Surgery 2009 49, 614-622DOI: (10.1016/j.jvs.2008.10.015) Copyright © 2009 Terms and Conditions