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A dangerous arrow

Nicola Mumoli, Giampiero Ferrito, Marco Cei
DOI: http://dx.doi.org/10.1093/eurheartj/ehm346 2849 First published online: 1 December 2007

A 75-year-old man underwent yearly follow-up carotid Duplex scanning after carotid endarterectomy (CEA), performed 3 years ago, because of the presence of a large atherosclerotic plaque at the bifurcation of left common carotid artery with severe stenosis (80%). A residual atheroma was present post-CEA with a small stenosis.

His medical history was notable for well-controlled hypertension, type 2 diabetes mellitus, smoking, and hypercholesterolaemia; his medications were simvastatin, aspirin, enalapril, and metformin. He was asymptomatic and there was a left carotid bruit on examination.

Longitudinal carotid ultrasonography (Panel A) and power-Doppler imaging (Panel B) showed an ulcerated plaque below the left CEA, strongly resembled an arrow, with severe stenosis of 90% confirmed by conventional angiography (Panel C; the arrow indicates the severe stenosis and the arrowhead indicates the CEA).

Percutaneous transluminal angioplasty with stenting and cerebral protection using filter devices was successfully performed (Panels D and E, arrows).

No neurological deficits or cranial nerve palsy were noted after the procedure, and at 6 months of follow-up, the patient was asymptomatic, without signs of restenosis (Panel F).

Panel A. Longitudinal carotid ultrasonography showing the residual ulcerated plaque with severe 90% stenosis, below the left CEA, strongly resembling an arrow.

Panel B. Longitudinal carotid power-Doppler imaging showing the narrowed left common carotid artery, strongly resembling an arrow.

Panel C. Conventional digital subtraction angiography showing the severe stenosis (arrow) below the left CEA (arrowhead).

Panel D. Conventional digital subtraction angiography showing the stent (arrow) with normal blood flow after percutaneous transluminal angioplasty.

Panel E. Conventional Angiography showing the stent (arrow) after percutaneous transluminal angioplasty.

Panel F. Longitudinal carotid power-Doppler imaging showing the stent with normal blood flow.

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