Case Review
History
Figure 1. MRI and MRA show no acute infarction but severe stenosis of left MCA bifurcation.
Figure 2. CTP shows ischemia in the left basal ganglia region compared to the contralateral side.
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Treatment Strategy
• Stent and balloon angioplasty.
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Operation
Figure 3. Measurement.
Figure 4 GIF. 6F guiding catheter. Transend 205 was across the stenotic segment.
Figure 5 GIF. Gateway 2mm*15cm balloon was navigated to the stenotic segment of the left MCA.
Figure 6 GIF. Tension adjustment for the stability during balloon angioplasty.
Figure 7 GIF. The stenosis was dilated by the Gateway balloon with 8ATM for 2 minutes.
Figure 8 GIF. Angiography shows the relieved stenosis.
Figure 9 GIF. Wingspan 3mm*15cm stent was sent to the stenotic segment.
Figure 10 GIF. Wingspan 3mm*15cm stent was deployed.
Figure 11 GIF. The tip of stent system was stuck in the stent.
Figure 12 GIF. 1. Do not pull the system. 2. Deliver the microwire further for better supporting and push the stent system forward a little. 3. Retrieve the stent system while adjusting the system tense.
Video 2. Post operation angiography shows satisfied dilation of the stenosis with mild stenosis left. Tirofiban 16ml.
Video 3. No hemorrhage or embolism. Intact intracranial vessels.
Figure 13. Post-operative angiography shows improved distal flow compared to the span-operative angiography.
Figure 14. CT shows no hemorrhage.
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Post operation
Post operation:
Figure 15. 6 Month Follow Up CTA shows no restenosis.
Figure 16. 3 year follow up angiography shows improved dilation of stenosis compared to the post-operative angiography.
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Summary
2. In this case, guiding catheter was used to do angiography immediately after balloon angioplasty. Delivery balloon catheter to distal vessel and do balloon catheter angiography after balloon angioplasty is another option to confirm the intact of distal vessels.
3. According to the risk of exchange technique and the vasculature architect of stenotic segment, exchange microwire was not used in this case. In case of post-dilatation dissection, exchange microwire should be used in the stent delivery.
4. Next CTA follow up was suggested in 5-8 years.
5. Medication recommendation after follow up: Aspirin 100mg qd, Rosuvastatin 10mg qn, Losartan 0.1g qd