80 year old lady

An 80-year-old woman was a case of left subclavian artery stenosis and received stenting in 2010. Then she received balloon angioplasty for in-stent restenosis in 2012.  This time, she presented a 6-month history of recurrent dizziness during left arm exertion. 

Doppler ultrasonography showed reversed flow in the left vertebral artery with the monophasic waveform in the left subclavian artery, indicating stenosis in the left proximal subclavian artery with subclavian steal phenomenon.

Angiography disclosed left SA ostial in-stent restenosis. A large calcified atheroma was noticed near left subclavian artery orifice (Figure 1). 

A JR4 guiding catheter was used trans-femorally to engage to left SA ostium but failed. The left radial artery was cannulated and retrograde wiring across the SA stent was successful. During manipulation, the patient developed acute neurological deficits, including aphasia and right hemiparesis. Cerebral embolization with acute stroke to the left hemisphere was suspected according to neurological localization. Unfortunately, the previous stable aortic plaque became partially mobile with a distinctive “shaking” motion pattern. The shaking plaque then broke off during the advancement of the diagnostic catheter into the left common carotid artery. It dislodged and was flushed from the arch to descending aorta (Figure 2a, 2b). Left middle cerebral artery occlusion at M1 was confirmed immediately with cerebral angiography (Figure 3), and intra-arterial thrombectomy was executed successfully.

Careful evaluation of the aortic plaque morphology and distribution is crucial in any procedure involving the aortic arch. When ominous sign with shaking aortic plaque is observed, termination of any further procedure should be seriously considered to avoid ensuing disaster.