Event: right hemispheric event 4 days post uncomplicated right tcar performed on the (b)(6) 2017 for an asymptomatic 80-85% left internal carotid artery stenosis.The patient was readmitted on the (b)(6) 2017 with acute right ica stent occlusion after developing left sided weakness, gaze preference and breathlessness at home that morning.The patient subsequently passed away on the (b)(6) 2017; the cause(s) of death were: right middle cerebral artery stroke secondary to occluded right carotid stent.Fluid overload with pulmonary edema.Aspiration pneumonia.Past medical history: diabetes (managed by oral hypoglycemic agents); hyperlipidemia; prior left carotid endarterectomy for asymptomatic left ica stenosis; peripheral vascular disease; benign prostatic hypertrophy; chronic obstructive pulmonary disease; nephrolithiasis; interstitial lung disease; osteoarthritis; presumed peripheral neuropathy; intermittent claudication.Procedure: performed under general anesthesia.Surgical exposure of the right common carotid artery above the clavicle and percutaneous access to the left common femoral vein.Procedure completed under high flow rate flow reversal.The right internal carotid artery lesion (ica) was pre-dilated to 3mm followed by placement of a 9mm x 40mm enroute transcarotid stent.The stent was post-dilated to 5.5mm.Copious debris was seen in the external filter of the flow line of the enroute nps system.The skin to skin time was sixty three minutes and the flow reversal time was ten minutes.Post-procedure timeline: the patient had some issues with a period of postoperative hypotension on the evening of the procedure and he was treated with vasopressors.He was discharged home the following day (the (b)(6) 2017).The patient's wife measured his blood pressures at home and found them to be in the normal range (120mmhg systolic).The patient went to bed in the usual state of health on the (b)(6) 2017 and then woke up sometime in the morning around 0200 hours on the (b)(6) 2017 and reported using both arms and legs normally at that time.The patient was taken to mount desert island for review and an ultrasound demonstrated an occluded right carotid stent.It was felt by the neurologists that the patient was outside the window for intravenous thrombolysis.The nihss on admission was 15.He was subsequently transferred to eastern maine medical center.Initial ct scan of brain showed no obvious midline shift or significant right hemispheric hypo density but a cta scan confirmed initial duplex ultrasound reports of an occluded right carotid stent.The drug regime was altered; clopidogrel was withheld and iv heparin was commenced.An mri scan of brain was performed on the (b)(6) and demonstrated an occluded right ica, acute/recent infarct changes involving the right mca, anterior and posterior watershed zones and to a lesser extent aca as well as punctate acute/recent infarct changes on the left.The report concluded that "other considerations, less likely, include acute/recent embolic infarctions with a central cardiac source".Ct scans of brain performed on the (b)(6) demonstrated evolving right middle cerebral artery infarct zone, edema with mass effect and left sided midline shift causing worsening of the patient's neurological symptoms.The patient was transferred to palliative care and passed away as noted in the first paragraph of this document, above.Device implanted.
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Patient had transcarotid artery revascularization (tcar) of right internal carotid artery (rica) on thursday (b)(6) 2017 that was unremarkable.High flow reversal time 10min, skin to skin 63min under ga.Filter was full of soft debris post procedure.Patient was found monday (b)(6) 2017 on the floor of the bedroom.Patient was able to get up with assistance and walked to the car and was driven to the er.The patient was awake and responded well to commands.Hand grip was 1/5 of normal in the left upper extremity.Ct shows no completed stroke or infarct.Hospital heparinized him and pushed for a slightly above normal bp.Computed tomography angiography (cta) confirms a total occlusion of the stent and the carotid.The baseline (pre-procedure) imaging was reassessed.This was a right tcar with straightforward anatomy.Regarding stent sizing, the distal rcca measured 7.9mm and so a 9mm x 40mm stent was per ifu.The rica beyond the lesion measured 4mm and there is no acute bend beyond that might cause problems for stent through flow.Silk road medical representative was notified by the treating facility that patient passed away on (b)(6) 2017.
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