1. Thrombus Aspiration and Sequential Stenting in Bilateral Carotid Arteries for a Patient with Takayasu Arteritis Tianjin First Center Hospital Lu Chengzhi Guo qianyu Chen xin 天津市第一中心医院心内科 卢成志 郭倩玉 陈欣

2. History Female ， 36 years old Chief complaint: intermittent amaurosis for one month, arose from exertion, accompanied with tumbling Past history: Takayasu arteritis and pulmonary fibrosis for 3 years under oral prednisone management

3. Physical Examination RUE/LUE pulseless, LLE pressure 170/80 mmHg, RLE pressure 130/80 mmHg III/6 systolic murmurs in left carotid artery. Both lung clear. HR 72 bpm ， regular rhythm, no murmurs.

4. Laboratory Investigations Blood Rt ： Hb 110g/L WBC6.1X10 9/L Liver function and renal function: normal TC 6.31mmol/L TG 1.64mmol/L TC 6.31mmol/L TG 1.64mmol/L ESR ： 18mm/h CRP ： 0.76mg/dl Immune antibodies ： SSB(+) SSB(+) SSA(+) SSA(+) ANA: 1 ： 100 ANA: 1 ： 100 others:(-) others:(-)

5. Auxiliary Examinations ECG ： normal UCG: normal

6. Angiography Examination CAG ： 40% stenosis in LM ostium LAD normal LAD normal LCX normal LCX normal RCA normal RCA normal Ceberal angiography: ： Brachiocephalic trunk occlusive. Brachiocephalic trunk occlusive. Left carotid artery subtotal occlusive. Left carotid artery subtotal occlusive. Left subclavian artery: 90% stenosis Left subclavian artery: 90% stenosis left vertebral artery: 95% stenosis in ostium left vertebral artery: 95% stenosis in ostium

7. Brachiocephalic trunk occlusive Left carotid artery subtotal occlusive Left subclavian artery: 90% stenosis left vertebral artery: 95% stenosis in ostium

8. Treatment strategy Conservative therapy? Interventional therapy? Carotidendarterectomy?

9. Treatment strategy Medication ： prednisone cyclophophamide cyclophophamide Interventional therapy ： first step: stent in right carotid artery first step: stent in right carotid artery second step: stent in left carotid artery second step: stent in left carotid artery

10. Stenting in right carotid artery （ 2009-05-25 ） Approach ： right femoral artery Equipment ： 8F MPA1 Guiding catheter 8F MPA1 Guiding catheter guide wire guide wire distal end protective umbrella distal end protective umbrella 2.0×20mm×mm Avion balloon 2.0×20mm×mm Avion balloon thrombus aspiration catheter thrombus aspiration catheter 5.0×40mm Submarine balloon 5.0×40mm Submarine balloon 7.0×40mm Precise stent 7.0×40mm Precise stent

11. 2.0×20 balloon dilation 2.0×20 balloon dilation After dilation

12. Distal end potective unmbrella 5.0×40mm balloon

13. After thrombus aspiration Thrombus before aspiration

14. 7.0×40 Precise stent Post dilation

15. Final result

16. Postoperative treatment Aspirin 300 mg and clopidogrel 75 mg Nifedipine to control BP Prednisone The patient’s ESR rose transiently and then fell normal, she didn’t feel dizziness or amaurosis any more.

17. Stenting in left carotid artery （ 2009-06-22 ） Approach ： right femoral artery Equipment ： 8F MPA1 Guiding catheter 8F MPA1 Guiding catheter 2 guide wire 2 guide wire 2.0×20mm×mm Invatec balloon 2.0×20mm×mm Invatec balloon distal end protective umbrella distal end protective umbrella 5.0×30mm Invatec balloon 5.0×30mm Invatec balloon 7.0×40mm Cordis stent 7.0×40mm Cordis stent

18. 2.0×20mm×mm Invatec balloon Before operation right carotid artery

19. 5.0×30mm Invatec balloon 7.0×40mm Cordis stent Final result

20. Discussion Endovascular interventional therapy: an approach to occlusive lesion of arteritis: Is it a suitable option? Thrombus aspiration: the first attempt dealing with thrombotic complications of stenting in carotid: Is it a lucky hit or a mandatory practice? medication or stenting in subclavian artery: Is it done or overdone? Antiplatlete therapy: duration and dosage.

21. Follow up No dizzness or amaurosis until now ESR 15-25 mm Medication: prednisone 5 mg QD prednisone 5 mg QD Aspirin 100 mg Aspirin 100 mg clopidogrel 75 mg QD for 6 Months clopidogrel 75 mg QD for 6 Months 8 month later CTA examination

22. 8 months later CTA show restenosis Stent in right carotid artery

23. Stent in left carotid artery

24. Discussion What to do with restenosis now: Intervention: bilateral balloon dilation? Intervention: bilateral balloon dilation? Conservative treatment? Conservative treatment? Carotidendarterectomy? Carotidendarterectomy?