Concomitant asymptomatic internal carotid artery and persistent primitive hypoglossal artery stenosis treated by endovascular stenting with proximal embolic protection

The persistent primitive hypoglossal artery (PPHA) is a rare fetal variant of carotid-basilar anastomosis that increases the risk of ischemia and embolic infarction within the posterior cerebral circulation in patients with carotid stenosis proximal to the origin of the PPHA. A man presented with severe stenosis of the right internal carotid artery with extension to the origin of a PPHA. The area of stenosis was at a high position, which contraindicated carotid endarterectomy. Therefore, stenting was performed with proximal reversal of flow embolic protection. The unique anatomic and technical challenges associated with this case are reviewed in detail.