Needle fenestration of popliteal artery covered stent graft to salvage inadvertent stent misdeployment.

Endovascular methods have transformed treatment of lower extremity peripheral arterial disease but can still present technical challenges. We report the case of a 69-year-old man with rest pain who underwent superficial femoral artery recanalization with covered stents. During completion angiography, the distal stent was discovered to have been misdeployed into an anterior geniculate branch overlying the behind-the-knee popliteal artery. Subsequently, an endovascular reentry device was used to fenestrate the stent posteriorly to enter the lumen of the popliteal artery. Cutting balloons were used to enlarge the fenestration in the stent fabric, with placement of an additional 6 × 50-mm covered stent bridging from the popliteal artery into the fenestrated misdeployed covered stent. Completion angiography demonstrated no evidence of distal embolization and patent two-vessel runoff. The patient had an uncomplicated recovery and at 2 years of follow-up remained asymptomatic with documented popliteal stent patency.

Thrombosis or vasospasm: The utility of intraoperative neuromonitoring during TCAR.

OBJECTIVES: Transcarotid artery revascularization (TCAR) has become more prevalent as a treatment modality for carotid stenosis. Many centers perform TCAR without any adjunctive neuromonitoring, for example, somatosensory-evoked potential (SSEP) and electroencephalogram (EEG). METHODS: We present a case of transcarotid artery revascularization (TCAR) performed with concomitant somatosensory-evoked potential (SSEP) and electroencephalogram (EEG) neuromonitoring in the setting of concerning intraoperative angiographic images. RESULTS: TCAR was undertaken for a 58 year-old man presenting with symptomatic left carotid stenosis and right ICA occlusion. Based on his comorbidities, pre-existing conditions, and the need for dual antiplatelet therapy, TCAR was offered as an alternative to standard carotid endarterectomy. Intraoperatively, following stent delivery, no flow was appreciated through the carotid stent or distal ICA. Neuromonitoring remained stable and was reassuring for distal ICA spasm with no-reflow phenomenon. The patient tolerated the procedure well and has had no stent-related complications through 10 months of follow-up. CONCLUSION: This case highlights the utility of neuromonitoring with TCAR as an adjunct to intraoperative decision-making in the setting of suspected internal carotid artery (ICA) vasospasm versus thrombosis after stent delivery.