Role of intraoperative intravascular ultrasound in the prevention of periprocedural complications during internal carotid artery stenting. A case report

Carotid angioplasty with stenting (CAS) is an alternative to surgery in patients with high surgical risk after carotid endarectomy. According to the large randomized controlled trial Carotid Revascularization Endart-erectomy versus Stenting (CREST), there are no significant differences in the rates of stroke, myocardial infarction, or death in the long-term follow-up between the CAS and carotid endarectomy groups. However,a significant number of complications in the CAS group are associated with the periprocedural period. The safety of CAS directly depends on the technical success of the procedure and minimizing the risk of cerebral embolism. Despite the use of embolic protection in 100% of cases, stroke prevention remains a pressing issue. A clinical case demonstrates the impact of intraoperative intravascular ultrasound (IVUS) on interventional tactics and complication prevention in CAS, and an algorithm for managing intraprocedural plaque protrusion is proposed.

This case confirms that IVUS is not simply a diagnostic tool, but a strategic tool that enables individualized treatment at all CAS stages. Routine use of IVUS for plaque morphology assessment, intraoperative monitoring, and complication management can significantly improve procedural safety. A management algorithm for patients with plaque protrusion is proposed.

1. Brott TG, Howard G, Roubin GS, et al. CREST Investigators. LongTerm Results of Stenting versus Endarterectomy for Carotid-Artery Stenosis. N Engl J Med. 2016;374(11):1021-31. doi:10.1056/NEJMoa1505215.

2. Rosenfield K, Matsumura JS, Chaturvedi S, et al. ACT I Investigators. Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis. N Engl J Med. 2016;374(11):1011-20. doi:10.1056/NEJMoa1515706.

3. Saba L, Cau R, Murgia A, et al. Carotid Plaque-RADS: A Novel Stroke Risk Classification System. JACC Cardiovasc Imaging. 2024;17(1):62-75. doi:10.1016/j.jcmg.2023.09.005.

4. Tekieli L, Kablak-Ziembicka A, Dabrowski W, et al. Imaging modalitydependent carotid stenosis severity variations against intravascular ultrasound as a reference: Carotid Artery intravasculaR Ultrasound Study (CARUS). Int J Cardiovasc Imaging. 2023; 39(10): 1909-20. doi:10.1007/s10554-023-02875-1.

5. Mishra B, Pandit AK, Miyachi S, et al. Clinical Utility of Intravascular Ultrasound (IVUS) in Carotid Artery Interventions: A Systematic Review and Meta-analysis. J Endovasc Ther. 2022; 29(5):67891. doi:10.1177/15266028211064824.

6. Collet JP, Thiele H, Barbato E, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2021;42(14):1289-1367. doi:10.1093/eurheartj/ehaa575.

7. Zakaryan NV, Molokhoev EB, Boyarintsev VV, et al. Intravascular ultrasound-guided intracranial artery stenting in a patient with recurrent ischemic stroke: a case report. Cardiovascular Therapy and Prevention. 2024;23(6):3862. (In Russ.) Зdoi:10.15829/1728-8800-2024-3862. EDN: QKXWZB.

8. Osipova OS, Popova IV, Starodubtsev VB, et al. Outcomes of using various designs of carotid stents. Siberian Journal of Clinical and Experimental Medicine. 2021;36(1):30-7. (In Russ.) Оdoi:10.29001/2073-8552-2021-36-1-30-37.

9. Wodarg F, Turner EL, Dobson J, et al; Carotid Stenosis Trialists’ Collaboration. Influence of stent design and use of protection devices on outcome of carotid artery stenting: a pooled analysis of individual patient data. J Neurointerv Surg. 2018;10(12):114954. doi:10.1136/neurintsurg-2017-013622.

10. Matchin YuG. Intravascular Ultrasound Imaging of Coronary Arteries. Doctor.Ru. 2011;(7):12-20. (In Russ.)