Iatrogenic Ascending Pharyngeal Artery Injury by Predilation Balloon Inflation During Carotid Artery Stenting with Flow Reversal

Accepted Manuscript Iatrogenic ascending pharyngeal artery injury by pre-dilation balloon inflation during carotid artery stenting with flow reversal Junpei Koge, M.D., Tomonori Iwata, M.D., Shigehisa Mizuta, M.D., Yukihiko Nakamura, M.D., Ph.D., Shun-ichi Matsumoto, M.D., Takeshi Yamada, M.D., Ph.D. PII:

S1878-8750(17)31128-2

DOI:

10.1016/j.wneu.2017.07.028

Reference:

WNEU 6090

To appear in:

World Neurosurgery

Received Date: 17 May 2017 Revised Date:

5 July 2017

Accepted Date: 6 July 2017

Please cite this article as: Koge J, Iwata T, Mizuta S, Nakamura Y, Matsumoto S-i, Yamada T, Iatrogenic ascending pharyngeal artery injury by pre-dilation balloon inflation during carotid artery stenting with flow reversal, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.07.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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CASE REPORT

Iatrogenic ascending pharyngeal artery injury by pre-dilation balloon inflation

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during carotid artery stenting with flow reversal

Junpei Koge, M.D.1, 2, Tomonori Iwata, M.D.2, Shigehisa Mizuta, M.D.1, Yukihiko

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Nakamura, M.D., Ph.D.3, Shun-ichi Matsumoto, M.D.4, Takeshi Yamada, M.D., Ph.D.1

Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka City,

Fukuoka, Japan

Department of Vascular Neurology, Saiseikai Fukuoka General Hospital, Fukuoka City,

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Fukuoka, Japan

Department of Neurosurgery, Saiseikai Fukuoka General Hospital, Fukuoka City,

Fukuoka, Japan

Department of Radiology, Saiseikai Fukuoka General Hospital, Fukuoka City, Fukuoka,

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Japan

Corresponding author: Junpei Koge, MD Department of Neurology, Saiseikai Fukuoka General Hospital, 1-3-46, Tenjin, Chuo-ku, Fukuoka 810-0001, Japan 1

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Tel: +81927718151, Fax: +81927160185

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E-mail address: [email protected]

Key Words: ascending pharyngeal artery, carotid artery stenting, flow reversal,

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pre-dilation

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Abstract

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Background: The ascending pharyngeal artery (APA) may rarely arise from the common carotid artery bifurcation. We herein report an injury to the APA as an unusual complication of pre-dilation balloon inflation during carotid artery stenting (CAS) with

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flow reversal.

Case Description: A 73-year-old man presented with symptomatic severe left cervical

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internal carotid artery (ICA) stenosis. The left APA arose from the common carotid artery bifurcation. We performed CAS with flow reversal to decrease the risk of distal embolization. When we attempted to catheterize the ICA under roadmap guidance for pre-dilation, we did not notice that the balloon catheters had advanced into the APA

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because of the absence of an antegrade angiogram, and the APA was injured when the balloon catheter were inflated.

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Conclusions: Our case underlines the importance of performing a detailed anatomic assessment before CAS and ensuring adequate angiographic visualization during the

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procedure under flow reversal when the origin of the APA is in the vicinity of the origin of the ICA.

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BACKGROUND

The most common major complication of carotid artery stenting (CAS) is peri- and/or post-procedural stroke.1 A flow reversal technique may be employed during CAS to

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minimize the risk of ischemic complications in patients with severe stenosis or

intraluminal thrombus.2, 3 Unlike distal protection, an antegrade angiogram cannot

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usually be obtained to confirm correct catheter insertion during flow reversal conditions. Therefore, we continue the procedure mainly using roadmap guidance prior to flow reversal.

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The ascending pharyngeal artery (APA), a branch of the external carotid artery (ECA), provides an anastomotic vascular network to the lower cranial nerves and

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nasopharyngeal structures.4 Rarely, the APA arises from the common carotid artery (CCA) bifurcation near the internal carotid artery (ICA) origin.4 We herein describe a

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rare complication of CAS in which the APA was injured by pre-dilation balloon catheters, because of the anatomic features of the APA and the absence of an angiogram. The present case demonstrates a potential pitfall during CAS using a flow reversal technique.

CASE DESCRIPTION

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A 73-year-old man presented with symptomatic left cervical carotid artery stenosis. He had a history of hypertension, chronic heart failure and coronary artery disease.

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Magnetic resonance imaging (MRI) of the brain showed multiple infarcts in the left cerebral hemisphere. Black blood MRI of the neck showed a plaque with T1

hyperintensity. Carotid ultrasonography demonstrated a hypoechoic plaque with a

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mobile component on its surface. Digital subtraction angiography demonstrated 80%

stenosis according to the North American Symptomatic Carotid Endarterectomy Trial

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criteria, with an intraluminal thrombus in the left ICA (Figure 1A and B). The APA arose from the CCA bifurcation (Figure 1C). CAS was recommended to the patient because carotid endarterectomy was a high-risk procedure due to the combination of his severe chronic heart failure and coronary artery disease.5 CAS was planned 3 months

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after the initial admission because of disappearance of the intraluminal thrombus.

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Intervention

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Informed consent was obtained from the patient for the procedure.

CAS was performed under local anesthesia and systemic heparinization. A total of 10000 units of heparin was administered during the operation. Temporary cardiac pacing was performed for expected angioplasty induced bradycardia. A 9 Fr balloon-guiding catheter (Optimo; Tokai Medical Products, Aichi, Japan) was positioned in the left CCA, and a balloon catheter (Carotid Guardwire; Medtronic, Minneapolis, MN, USA) was introduced into the ECA. Flow in the ECA and CCA was 5

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blocked to bring about flow reversal. Using roadmap guidance, a 0.014-inch micro-guidewire and SL10 micro-catheter (Stryker, Kalamazoo, MI, USA) were gently

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advanced into the distal ICA. At this point, the micro-guidewire must have been inserted into the APA, but this was not evident without the benefit of an antegrade angiogram. The micro-guidewire was running slightly rightward of the ICA on the left anterior

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oblique view. However, we were not concerned about the deviation because the entire roadmap was displaced slightly leftward due to the patient’s movement and was

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fluctuating due to respiratory motion. This caused the roadmap to become misleading. Three balloon catheters (Shiden 3 × 40 mm and Raiden 4 × 15 mm; Kaneka Corp., Osaka, Japan and Coyote 4 × 40 mm; Boston Scientific, Boston, MA, USA) were inadvertently navigated into the APA, and inflated to pressures of 8 atm (3 mm), 10 atm

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(4 mm), and 6 atm (4 mm), respectively, for 30 s. However, the balloons did not expand sufficiently and the patient complained of neck pain. After manual aspiration of blood

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from the balloon-guiding catheter, the CCA and ECA balloon was deflated. A left common carotid angiogram demonstrated that the ICA was occluded and that the APA

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was dilated. While the peripheral branch of the APA was poorly visualized, extravasation was not observed. The micro-guidewire successfully traversed the occlusion under flow reversal. A 10 mm × 31 mm Carotid Wallstent (Boston Scientific) was deployed over the ICA stenosis. A final angiogram demonstrated revascularization without residual stenosis, and no embolization in the intracranial arteries, but the APA remained occluded (Figure 2A-G). We reversed the heparinization with 40 mg of intravenous protamine. 6

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Postoperative course

Postoperatively the patient did not report neck pain, dyspnea or lower cranial nerve dysfunction. Computed tomography (CT) of the neck revealed a retropharyngeal

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hematoma and contrast material leakage medial to the carotid stent. On postoperative day 5, neck CT showed that the hematoma had resolved. The patient was discharged

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home on aspirin (100 mg daily) and clopidogrel (75 mg daily) on the postoperative day 7.

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DISCUSSION

We have herein described a case of iatrogenic injury to the APA during CAS under flow

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complication.

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reversal. We determined that both anatomic and technical factors contributed to this

The APA generally arises from the posterior wall of the proximal external carotid artery trunk, but in 2%–5% of autopsy cases the APA arises from the carotid bifurcation.4, 6 In the present case, because the APA originated near the ICA and ran parallel to it, we could not detect the incorrect placement of the micro-guidewire based on its shape. Although the APA was visible on the left anterior oblique view and discrete from the ICA, we did not sufficiently confirm the guidewire position on this view because of the 7

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poorly visualized roadmap. In similar cases, the APA arose from the ICA or the carotid bifurcation and were injured during placement of the distal protection device.4, 7

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Identifying and understanding the anatomic variations of the APA may help to prevent such complications.

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Our case differs from previous reports in that CAS was performed under flow reversal. The flow reversal technique creates retrograde flow in the ICA and prevents distal

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migration of debris.2 An antegrade angiogram cannot usually be obtained under flow reversal conditions. When it is difficult to refer to the roadmap with adequate visualization, a small injection of contrast should be administered through the micro-catheter before exchanging it a balloon catheter to confirm that the micro-catheter

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is in the correct position. Although it is suboptimal to inject contrast during flow reversal, this should be performed when there is concern regarding a possible

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complication.

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Two unusual incidents occurred during the operation. First, the patient complained of neck pain during balloon dilation; reports of cervical pain during CAS and balloon angioplasty are unusual.8 Second, the balloon catheters did not expand sufficiently despite the presence of a vulnerable plaque, and assumed the characteristic shape of a gourd upon inflation. Mismatch of the balloon size and artery diameter may lead to an increase in intra-arterial pressure, insufficient balloon expansion and neck pain.9

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Retropharyngeal hematomas are rare and generally occur spontaneously; they may also be provoked by trauma, vertebral artery aneurysm, thyroid hemorrhages, or tumors.10

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Because a retropharyngeal hematoma may cause life-threatening airway obstruction, the bleeding vessel should be promptly embolized when extravasation is confirmed.11 Even if no extravasation is apparent, heparin reversal should be performed, as in the present

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potential for delayed life-threatening hemorrhage.

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case. Moreover, embolization of the injured vessel should be considered to prevent the

CONCLUSIONS

Careful preoperative assessment of the anatomy and the knowledge of anatomic

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variations of the APA are important before CAS, especially if this procedure is to be performed under flow reversal. Our case also underscores the importance of adequate

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angiographic visualization to provide all necessary imaging during procedure. Judging the position of the guidewire based only on its shape may be insufficient to avoid a

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potentially severe iatrogenic injury. When unusual deformation of the balloon catheter is observed or neck pain is reported during CAS, flow reversal should be interrupted and an antegrade angiogram performed to confirm the correct placement of the balloons.

Funding

This research did not receive any specific grant from funding agencies in the public, 9

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commercial, or not-for-profit sectors.

1. Brott TG, Hobson RW

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REFERENCES

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Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363:11-23.

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3. Bode A, Franke J, Rabe K, Homung M, Wunderlich N, Bertog SC, et al. Acute and long-term results of carotid stenting under proximal embolic protection using the

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The ascending pharyngeal artery and its relevance for neurosurgical and endovascular procedures. Neurosurgery. 2009;65(ONS Suppl 1):ons114-ons120.

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2005;45:25-29. 7. Ecker RD, Guidot CA, Hanel RA, Wehman JC, Sauvageau E, Guteman LR, et al.

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10. Munoz A, Fischbein NJ, de Vergas J, Crespo J, Alvarez-Vincent J. Spontaneous retropharyngeal hematoma: diagnosis by MR imaging. AJNR. 2001;22:1209-11.

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11. Sheath K, Hui F, Wansaicheong G, Khoo M. Retropharyngeal haemorrhage from a vertebral artery branch treated with distal flow arrest and particle embolization.

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Singapore Med J. 2006;47:719-723.

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Figure captions

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Figure1. Angiogram at baseline. A, B: Anteroposterior (A) and lateral (B) views of the angiogram show high-grade left carotid artery stenosis, an intraluminal thrombus

(arrow) and the ascending pharyngeal artery (arrowheads). ; C: Posterior view of a

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three-dimensional rotational angiogram shows the ascending pharyngeal artery arising

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from the common carotid artery bifurcation (arrowhead).

Figure 2. Carotid artery stenting procedure. A, B: Left anterior oblique (A) and lateral (B) views of the preoperative angiogram show severe stenosis in the left ICA; C: Proximal balloon protection is achieved in the common carotid artery and external

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carotid artery, and a 0.014-inch micro-guidewire is gently advanced into the distal ICA using roadmap guidance. However, the micro-guidewire must have been inserted into

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the APA (left anterior oblique view). D, E: Pre-dilation by balloon catheters is performed under flow reversal, but the balloons do not expand locally (arrow); F:

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Lateral view of the post balloon angioplasty angiogram shows the dilated APA and the occluded ICA; G: Lateral view of the postoperative angiogram shows that the left ICA is successfully dilated, but the peripheral branches of the APA are poorly visualized. ICA = internal carotid artery; APA = ascending pharyngeal artery.

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Highlights

2. Postoperatively, mild retropharyngeal hematoma occurred.

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1. Iatrogenic ascending pharyngeal artery injury during carotid artery stenting.

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3. Careful assessment of the anatomy before carotid artery stenting is important.

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Abbreviations and Acronyms: APA: Ascending pharyngeal artery

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CAS: Carotid artery stenting ICA: Internal carotid artery ECA: External carotid artery

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CCA: Common carotid artery

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CT: Computed tomography

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MRI: Magnetic resonance imaging