Double embolic protection during carotid artery stenting with persistent hypoglossal artery

Abstract

A woman presented with 75% stenosis of the right internal carotid artery (ICA) with extension to the origin of a persistent hypoglossal artery (PHA). The PHA is a rare fetal variant of carotid-basilar anastomosis that elevates the risk of ischemia and embolic infarction within the posterior cerebral circulation in patients with carotid disease proximal to the anastomosis. Our case is highly unique because of the extremely rare nature of the PHA with associated ICA stenosis that extended to the PHA. Additionally, a novel treatment approach was employed by stenting and angioplasty while protecting both the anterior and posterior cerebral circulations.

Endarterectomy of carotid artery bifurcation in the setting of a persistent hypoglossal artery and anomalous collateral vascular supply

“…Alternatively, carotid stenting of the carotid bifurcation and proximal ICA with duplicate distal protection devices in both the proper ICA and HGA has been reported. 23 This technique requires jailing of one of the distal protection devices outside the stent, which needs to be withdrawn on completion. The use of flow arrest or reversal protection such as transcarotid artery revascularization in this case would not be ideal because of the poor collateral circulation.…”

Concomitant asymptomatic internal carotid artery and persistent primitive hypoglossal artery stenosis treated by endovascular stenting with proximal embolic protection

“…6 Current treatment options for ICA stenosis extending near or beyond the bifurcation into the PPHA or for stenosis of the PPHA itself include CEA 7,8 and CAS, with the use of distal or proximal flow arrest 9,10 or distal filter embolic protection devices. 11 In our case, treatment with CEA would have involved removal of plaque from both the ICA and PPHA. The distal PPHA stenosis reached the C1 vertebral body level.…”

Persistent Hypoglossal Artery: Challenges Associated With Carotid Revascularization

“…6,7 More recently, transfemoral carotid stenting has been reported as an alternative to open surgical revascularization in the setting of a PHA. 8,9 In both reported cases, the authors utilized distal embolic protection (balloon occlusion in the former and 2 distal filters in the latter) and were able to deploy the stent from the CCA to immediately below the ICA/PHA bifurcation because of an adequate cephalad landing zone. In these cases, the lesions did not appear to be heavily calcified.…”