Feasibility of carotid artery stenting in patients with angiographic string sign

Treatment of angiographic string sign (SS) of the carotid artery with carotid endarterectomy or carotid artery stenting (CAS) has been associated with a high incidence of periprocedural neurological events. We describe our experience with CAS in a case series of symptomatic patients with severe carotid stenosis and angiographic SS.

We performed a retrospective review from 1999 to 2009 using our cardiac cath laboratory database and identified nine patients with the angiographic SS who underwent CAS. All patients were referred for carotid angiography by a neurologist due to symptoms (stroke or transient ischemic attack (TIA)). All lesions were predilated and treated with self-expanding stents. Distal protection devices were utilized (six patients) once they became available. Periprocedural outcomes and long-term follow-up was reviewed when available.

The average time from onset of symptoms to CAS was 45 days. All CAS procedures were technically and clinically successful without acute complications. One year follow-up was available in eight patients. One patient had a possible TIA, and the remaining seven patients did not report any events (death, stroke, TIA or myocardial infarction). Carotid ultrasound evaluation at 12 months was available in six patients and showed no evidence of restenosis.

In our experience, CAS in patients with severe symptomatic carotid stenosis and angiographic SS is feasible, with an acceptably low periprocedural complication rate.