Carotid Artery Stenting in a Patient With Internal Carotid Artery Stenosis and Ipsilateral Persistent Primitive Hypoglossal Artery Presenting With Transient Ischemia of the Vertebrobasilar System -Case Report-

Abstract

A 62-year-old man experienced transient episodes of vertigo associated with left upper extremity weakness. Cerebral angiography showed 75% right internal carotid artery (ICA) stenosis and divergence of a persistent primitive hypoglossal artery (PPHA) distal to the stenosis. The area of stenosis was at a high position and he had a past medical history of congestive heart failure, which contraindicated carotid endarterectomy (CEA). Therefore, carotid artery stenting (CAS) was performed with single distal balloon protection. The stenotic area was restored and he was discharged without suffering recurrent attacks. CAS may be an effective alternative treatment to CEA to prevent further ischemic attacks in the posterior circulation in patients with PPHA. CAS using simple embolic protection devices is possible if the distance between the distal end of the ICA stenosis and the origin of the PPHA is sufficiently long.

Stent Placement for Stenosis at the Origin of a Persistent Primitive Proatlantal Artery: A Case Report

“…8,9) Regarding stroke, there have been reports that cerebral infarction was caused by the occlusion of a persistent artery due to the dissection of the ICA or by an embolus carried through a persistent primitive artery, 10,11) but reports of the stenosis of a persistent primitive artery causing stroke are rare. In intracranial endovascular treatment, there have been sporadic reports of stenting for ICA stenosis complicated by PPHA or PPPA; [12][13][14] however, only two cases of stenting for stenosis of PPPA have been reported. 15,16) Concerning the two previous cases in the literature, one was of a 78-year-old man who presented with diplopia and disturbance of sensation and was found to have multifocal Regarding future problems, the risk of restenosis exists, and restenosis rates after stenting at the origin of the vertebral artery have been reported to range from 25% to 43.3%.…”

Double embolic protection during carotid artery stenting with persistent hypoglossal artery

“…However, in cases in which the stenosis is immediately proximal to the origin of the PHA, the use of a distal embolic protection device may be difficult because of the tortuousity of the vessels 6 15Learning points

CAS involving the ICA and the origin of the PHA presented a challenge for distal embolic protection and the necessity to protect both vessels from emboli.

The significant decrease in carotid blood flow associated with a stenotic carotid artery potentially places both the ipsilateral anterior and posterior circulations under ischemia 9

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Double embolic protection during carotid artery stenting with persistent hypoglossal artery

“…Previously, the successful use of a single distal protection device was reported in a patient with sufficient length between the ICA stenosis and the PHA origin 6. Although there are reports that find no statistically significant difference in the efficacy of flow arrest using proximal balloon occlusion versus the use of distal filter embolic protection devices,7 flow arrest by use of balloon occlusion devices does so at the expense of constant procedural cerebral perfusion and may not be tolerated in patients with decreased cerebral vascular reserve, incomplete circle of Willis and/or high grade stenosis of the contralateral ICA 8.…”

“…Current treatment options for ICA stenoses extending near or beyond the bifurcation into the PHA or for stenoses of the PHA itself include balloon angioplasty, CEA and CAS, with the use of proximal flow arrest or distal filter embolic protection devices 6 11 12…”

“…However, in cases in which the stenosis is immediately proximal to the origin of the PHA, the use of a distal embolic protection device may be difficult because of the tortuousity of the vessels 6 15Key messages

CAS involving the ICA and the origin of the PHA presented a challenge for distal embolic protection and the necessity to protect both vessels from emboli.

The significant decrease in carotid blood flow associated with a stenotic carotid artery potentially places both the ipsilateral anterior and posterior circulations under ischemia 9

…”