Combined Carotid Artery Stenting and Coronary Stenting in Metachronous Cardiocerebral Infarction.

Dear Editor,

Carotid artery stenting (CAS) and percutaneous transluminal coronary angioplasty (PTCA) are infrequently performed in the same setting. The first reports emerged in 1996 in the acute setting of combined symptomatic neurological and cardiac ischemic events.[1] Thereafter, there have been only a few reports, in the literature.[2] This may be due to current guidelines that emphasize the small superiority of carotid endarterectomy over CAS. However, there is still a role for this combined technique in certain situations.

A 67-year-old diabetic, hypertensive man presented with facial deviation lasting for a couple of hours. He had a similar episode one year earlier. CT brain showed an acute infarct in the right MCA territory. CT Angiogram [CTA] revealed a complete occlusion of the Left Internal Carotid Artery [ICA] with 90% stenosis of the Right ICA. [Figure 1a-b] He was started on dual antiplatelets and atorvastatin. On day 2, he developed crushing chest pain. An ECG showed an inferior wall ST elevation myocardial infarction and Echocardiography showed Inferior wall hypokinesia. Coronary angiogram which revealed 80% discrete stenosis of proximal left anterior descending (LAD) artery and 80% tubular stenosis in the distal left circumflex artery (LCX). The proximal Right Coronary Artery (RCA) was occluded and the distal RCA was filled by retrograde filling via collateral flow from the left side. The patient was presumptively planned for Coronary Artery Bypass Graft surgery (CABG) with concurrent carotid endarterectomy (CEA). Review of the CTA images showed a very high ICA bifurcation lying nearly at the angle of the mandible, which made surgery technically difficult. The angle of mandible presents a significant barrier to surgical access for CEA. The option of Carotid Artery Stenting (CAS) followed by CABG was offered to the patient. As he was keen to undergo PTCA instead of a CABG, it was decided to do a simultaneous right ICA CAS followed by PTCA to LAD and LCX.

Figure 1

a. Hypodensity in the right M1 MCA territory. b. Right proximal ICA show shows a near concentric mixed density plaque (predominantly calcified) causing ~ 90-100% luminal narrowing. c. DSA showing more than 90% stenosis of the proximal Right ICA. d. Post Stenting Angiogram of the right ICA. e. Coronary Angiogram revealing a 80% stenosis of proximal-mid Left Anterior Descending artery. f. Post Angioplasty of LAD shows TIMI Grade 3 Flow. g. Coronary Angiogram revealing an 80% Stenosis of the Left Circumflex artery. h. Post Angioplasty of the LCX artery shows TIMI Grade 3 flow

Under local anesthesia, Digital Subtraction Angiography [DSA] was performed which showed a 90% stenosis of the Right ICA 2 cm distal to the carotid bifurcation. [Figure 1c] After placing a 90 cm Flexor® Raabe long sheath, an Abbott Emboshield NAV 6™ embolic protection device was deployed distal to the lesion. Angioplasty of the lesion was achieved using a 2 mm × 15 mm Artemis and a 6 >8 mm × 40 mm Abbott X-ACT®self-expanding stent was deployed across the lesion. Post stenting dilatation was done with a 4 mm × 12 mm Sapphire® non-compliant balloon. Post stenting angiogram showed good flow. [Figure 1d] After this the LAD coronary artery was engaged with a 7F EBU 3.5 guiding catheter. The lesion was crossed with a BMW guidewire. Pre-dilatation was done with an Artemis 2.0/15 mm balloon and the proximal-mid LAD was stented with a Xience Xpedition™ 2.75/38 mm drug-eluting stent. After post dilatation with a Sapphire® NC 2.75/15 mm balloon, the stent was noticed to be well expanded and TIMI 3 flow was noted. The left circumflex artery was next cannulated and stented with an Apollo NC 2.5/12 mm balloon. Again, the stent was seen to be well expanded and TIMI 3 flow was obtained. [Figure 1e-h] The procedure was uneventful and the patient was discharged with a Rankin score of 0 on day 5.

At 6 months follow up, he was stable and asymptomatic.

There is a higher risk of acute myocardial infarction after a TIA or an acute stroke.[3] During the acute stroke treatment itself, 1% of patients with an ischemic stroke and 0.3% of patients with haemorrhagic stroke develop a myocardial infarction.[4] Many of these patients have elevated serum troponin levels alone and NSTEMI [non ST elevation MI] is far commoner than STEMI [ST elevation MI]. Thus coronary culprit lesions are seldom problematic in acute stroke patients.[5] The reverse is also true. In the setting of an acute coronary syndrome or MI, around 0.9% of patients develop an acute stroke. This proportion is higher in those with an STEMI and more so within the first 5 days after an acute MI.[6] Simultaneous or 'Synchronous’ stroke and acute MI occurring together is even more rare and occurs in around 0.009% of cases.[7] The term 'Synchronous Cardiocerebral’ infarction [SCI] has been used in these cases. Often, a stroke or an MI occurs first and is shortly followed thereafter by the other event. This is referred to as a ‘Metachronous cardiocerebral infarction’ [MCI]. The underlying causes of SCI are slightly different and hence management protocols differ. MCI is also underreported and rare and hence there are no guidelines for the management of these patients. As our patient had concurrent atherosclerotic coronary steno-occlusive lesion and a surgically inaccessible carotid lesion, the options were CAS followed by CABG or a combined CAS + PTCA. Our case documents the rare scenario of an MCI and the utility of combined CAS + PTCA in special situations.

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Conflicts of interest

There are no conflicts of interest.