Treatment of Global Cerebral Hypoperfusion in a Patient with Innominate and Left Common Carotid Artery Stenosis

Document Type

Article

Publication Date

10-2026

Publication Title

Journal of Vascular Surgery

Abstract

Background: Global cerebral hypoperfusion is an uncommon but clinically significant cause of transient ischemic attack (TIA), most often resulting from high-grade stenosis of the supra-aortic vessels. Tandem lesions involving the innominate and common carotid arteries are rare and may produce diffuse, bilateral neurologic symptoms that complicate diagnosis and management. Optimal revascularization strategy in this setting remains technically challenging, particularly in heavily calcified disease.

Case description: A 75-year-old woman with chronic obstructive pulmonary disease and hyperlipidemia presented with a 2-month history of recurrent dizziness, unsteady gait, bilateral visual disturbance, slurred speech, and transient left-sided weakness. Computed tomography angiography demonstrated severe calcified stenoses of the innominate artery and the origin of the left common carotid artery (Fig 1). A staged revascularization strategy was pursued to mitigate the risk of cerebral hyperperfusion syndrome (CHS). Initial transfemoral balloon angioplasty and stenting of the left common carotid artery resulted in temporary symptom resolution. Because of persistent TIAs, she subsequently underwent open retrograde intravascular lithotripsy and covered stent placement of the innominate artery. Postoperatively, she developed transient hypertensive urgency concerning for CHS, which resolved with intravenous antihypertensive therapy. At 1-year follow-up, imaging confirmed widely patent stents with complete symptom resolution (Fig 2).

Discussion: This case highlights the importance of recognizing global hypoperfusion from tandem supra-aortic stenoses as a cause of diffuse TIA symptoms. Intravascular lithotripsy facilitated safe treatment of heavily calcified innominate disease. A staged, stepwise revascularization approach may reduce the severity of CHS while restoring durable cerebral perfusion in complex multivessel pathology.

Volume

84

Issue

4

First Page

e368

Last Page

e369

Comments

Midwestern Vascular Society Annual Meeting, September 17-19, 2026, Chicago, IL

Frederik Meijer Heart and Vascular Institute

DOI

10.1016/j.jvs.2026.06.135

ISSN

0741-5214

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