Multicenter Experience with Stenting for Symptomatic Carotid Web

Abstract

Background: A carotid web (CaW) is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. CaW has been associated with recurrent strokes and conventionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic CaWs.

Methods: Retrospective review of consecutive patients admitted to 5 comprehensive stroke centers who were identified to have a symptomatic CaW and treated with carotid stenting. A symptomatic CaW was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT angiography (CTA) and confirmed with conventional angiography in patients with negative stroke workup.

Results: Twenty-four patients with stented symptomatic CaW were identified (stroke in 83% and transient ischemic attack in 17%). Their median age was 47 years (IQR 41-61), 14 (58%) were female, and were 17 (71%) black. The degree of stenosis by NASCET was 0% (range 0-11). All patients were placed on dual antiplatelets and stented at a median of 9 days (IQR 4-35) after the last event. Closed-cell stents were used in 18 (75%) of the cases. No periprocedural events occurred with the exception of 2 cases of asymptomatic hypotension/bradycardia. Clinical follow-up after stent placement occurred for a median of 12 months (IQR 3-19) with no new cerebrovascular events noted. Functional independence at 90 days was achieved in 22 (91%) patients. Follow-up vascular imaging (ultrasound n = 18/CTA n = 5) was performed at a median of 10 months (IQR 3-18) and revealed no stenosis.

Conclusions: Stenting for symptomatic CaW appears to be a safe and effective alternative to surgical resection. Further studies are warranted.

Keywords: Carotid web; Fibromuscular dysplasia; Stent; Stroke.

Fig. 1.

A 57-year-old man with hypertension and middle cerebral artery stroke. a Lateral digital subtraction angiography of the common carotid artery indicating the CaW. b Fluoroscopy after closed-cell stenting depicting minimal residual waist (white arrowhead) and contrast stagnation within the web pocket (arrow). c Early arterial angiography following stenting. d Venous phase (black arrowheads delineating the margins of the internal jugular vein) with trapping of contrast within the excluded web pocket.

Fig. 2.

A 61-year-old woman with no risk factors and anterior circulation stroke. a Left anterior oblique conventional angiography indicating the CaW. b Post-stent (arrowheads: stent margins) angiography demonstrating the remodeling of the CaW pocket (arrow). c A 21-month post-stent CTA angiography showing endoluminal reconstruction (arrow: resolution of the CaW pocket; arrowheads: stent margins).

Fig. 3.

A 35-year-old man with no risk factors and anterior circulation stroke. a 3D rotational conventional angiogram of the common carotid artery depicting the web. b Mid-arterial phase of the common carotid artery subtraction angiogram. c Maximum intensity projection. d Source image of a 19-month CT angiogram follow-up indicating vessel remodeling with no stenosis.