Stenting of a Right Carotid Bypass graft distal anastomosis with MOMA device protection

Clinical Data:

• Man, 43 years, nicotine abuse,
• 1993: Hodgkin disease with radiotherapy
• 2010: right common/right internal carotid artery bypass
• 2011, january: right external iliac artery stenting
• 2011, october: severe stenosis at the distal anastomosis of the bypass and development of a tight stenosis of the left common carotid artery 
• 2011, november: stenting of the left common carotid artery

Previous imaging:

• Duplex: good result of previous stenting of the left common carotid artery, Severe stenosis of the carotid bypass
• 3D Rotational angiography: important toruosities distal to the stenosis

Learning objectives:

• How to treat bilateral carotid artery stenosis?
• how to stage and how to schedule patients in case of bilateral carotid artery stenting?
• What are solutions for embolic distal protection and how to choose between the different devices available?

Procedural steps:

1. access: 

• Right femoral access, 9F, 23 cm BRITE TIP ® sheath, Cordis
• Canulation of the Right Common Carotid Artery with an angiographic catheter 5F, 100 cm, SIM 2 Super Torque, Cordis, advanced upon a 0,035" Radiofocus Terumo angled stiff guidewire M-type, 260 cm

2. Proximal protection device placement

• Exchange with a 0,035" - 260 cm, Amplatz Super Stiff Guidewire
• Placement of a 13 (proximal balloon) x  6 (distal balloon) 9F, Mo.Ma^® Ultra device, Invatec, with the distal balloon being in the right external carotid artery and the proximal one in the right common carotid artery.  
• Deploiement  of the distal balloon
• Exchange of the guidewire to a BMW II  0,014" - 190 cm
• Deploiement of the proximal balloon

3. Predilation, stenting and postdilation:

• Predilation with a 4 x 20 mm  ultra Soft SV balloon, Boston Scientific
• Deploiement of a 8 x 20 mm Precise Pro Rx stent, Cordis
• Postdilation with a 5 x 15 mm Ultra Soft SV balloon, Boston Scientific

4. Debris removal:

• First aspiration of 2 seringes with the two balloon closed
• Deflation of the distal balloon and second aspiration, with the proximal balloon only inflated
• Deflation of the proximal balloon