Abstract
A 48-year-old, Caucasian female with a history of protein S deficiency presented with an asymptomatic, flow-limiting stenosis of the left internal carotid artery (ICA) secondary to a carotid web. She reported an episode of right upper extremity weakness and dysphasia 2 years ago but this resolved with dual antiplatelet therapy and oral anticoagulation. A computed tomography angiogram (CTA) revealed a focal, noncalcified, 75% stenosis of the carotid bulb consistent with a carotid web (Panels A and B, arrow). Utilizing the standard dissection techniques for a carotid endarterectomy, the carotid vasculature was exposed. An intraoperative duplex ultrasound confirmed preoperative velocities (proximal ICA:PSV (peak-systolic velocity) = 309 cm/s, EDV (end-diastolic velocity) = 103 cm/s, ICA:CCA (common carotid artery) ratio = 4:1), and showed a mobile web in cadence with systole and diastole (Panel C, arrow). A longitudinal arteriotomy traversing the carotid bulb was performed, and a carotid artery web was excised (Panel D). A bovine pericardial patch angioplasty completed the repair. Postprocedure intraoperative duplex ultrasound showed normal velocities and a patent carotid system. Her postoperative hospitalization and clinic visit were uncomplicated with regards to neurologic deficits and she endorsed improved cognition.
A carotid web is a thin shelf of intimal hyperplastic tissue extending from the artery wall intraluminally, and is most commonly located at the origin of the ICA. It is generally described as an atypical, intimal variant of fibromuscular dysplasia, increasingly recognized as a cause of recurrent strokes. Carotid webs impede blood flow and promote stagnation, thrombus development, and, ultimately, the possibility of embolic sequelae. 1 They represent an underappreciated source of cryptogenic ischemic strokes. Recent studies have reported that carotid webs may represent approximately one-third of cryptogenic ischemic strokes and that there is a high prevalence in young, female, and black patients.2,3 These webs are diagnosed by CTA, demonstrating a focal, linear intraluminal filling defect along the posterior wall of the proximal ICA, often with superimposed thrombus.
Treatment practices are evolving. Recurrent strokes, despite antiplatelet therapy, have prompted the use of anticoagulation or surgery for initial management. Dissolution of superimposed carotid web thrombus has been shown by anticoagulation but there are no studies directly comparing this to surgical management. 1 Procedural options include carotid web resection or carotid stenting. Patients treated procedurally have lower rates of recurrent neurologic symptoms than those treated with antiplatelet therapy.1,3 Interestingly, stroke risk does not appear to correlate with degree of stenosis created by the carotid web, as in atherosclerotic disease.
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Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
