Carotid
CEA

Unusual carotid enlargement after CEA

An 80-year-old patient with coronary disease, diabetes, and a history of stroke presents with a left carotid patch enlargement and tight stenosis before the venous patch—yet the carotid bifurcation and distal internal carotid remain patent.

With a complex vascular history, including previous carotid surgery and recurrent strokes, this case raises a critical question: How would you manage the next steps?

Caroline Caradu
Caroline Caradu
Bordeaux, France
Éric Ducasse
Éric Ducasse
Hospital Pellegrin - Bordeaux, France
Professor of vascular surgery

Professor of vascular surgery
Head of unit of vascular surgery CHU Bordeaux - France

Conflicts of interest:

Honoraria from: COOK Médical, Térumo-Vascutek, Siemens, GORE

Part I - Case presentation

A 80-year-old patient presented with :

  • Coronary diseases / Diabetic status / Dyslipidemia
  • Previous carotid surgical treatment on left side with venous patch closure in 2014 in another peripheral center
  • Previous history of stroke in 2016 and 2022 with excellent recovery. Clinical transient history of right brachial deficit and paresthesia
  • Recent investigation with Angio CT scan showing:
    • Left carotid patch enlargement without thrombus
    • Left common carotid tight stenosis before venous path
    • Carotid bifurcation patent
    • Distal left internal carotid patent without stenosis
Unusual carotid enlargement after CEA
Unusual carotid enlargement after CEA
Unusual Carotid enlargement after CEA

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Part II - Our treatment

Our decision: 

  • Right common femoral artery access
  • Catheterism of left common carotid
  • Embolisation of external carotid artery
  • Exclusion on carotid enlargement with self-expanding covered stent
  • Angioplasty of proximal stenosis
  • Dual anti-platelet medication post operative period

Per operative angiogram from right femoral access

  • Carotid bifurcation enlargement
  • Tight stenosis at the proximal edge of the venous patch
  • External carotid artery patent
  • Absence of lesion on the internal carotid artery
     

Per operative embolisation of external carotid artery

  • Direct catheterism with 0.018 wire
  • Direct 7 Fr sheath placement
  • Angiogram control

External carotid embolisation

  • 5 Fr plug placement at the ostium of external carotid artery to avoid any retrograde perfusion
  • Control with perfect plug placement and provisional arterial perfusion maintained
External carotid embolisation

Exclusion of carotid enlargement 

  • 0.018 guidewire placement in internal carotid artery
  • No protection device added
  • Viabahn 7 x 75 mm delivered
  • Precise deployment and delivery

Final angioplasty

  • Proximal angioplasty on tight stenosis at 8 atm using 6 x 4 mm balloon
  • Distal angioplasty at 4 atm same balloon
  • Angiogram control showing excellent result without residual stenosis 
Angiogram control showing excellent result without residual stenosis

Intra-cerebral angiogram

  • Absence of embolism
  • Perfect perfusion without defect
  • Patient delivered at D+ 1
  • Dual anti-platelet medication during at least 3 months