Thrombectomy by Direct Cervical Access in Case of Common Carotid Occlusion with Collateral Supply to Internal Carotid Artery: Uncommon Anatomic Variant

Radiographic Anatomy of the Common Carotid Artery for Direct Carotid Puncture

BACKGROUND

Direct common carotid puncture (DCP) is conventionally used as a bailout technique in stroke patients. However, little is known about the relevant anatomy. Our objective was to examine the relationship of the common carotid artery (CCA) to surrounding structures based on different DCP trajectories passing through the artery's center.

METHODS

Fifty randomly selected head/neck CTAs were analyzed. The trajectory of DCP and relationship to the internal jugular vein (IJV) and thyroid were analyzed at 1 cm intervals above the clavicle on 7 axial sections. Using the trans-carotid sagittal plane as the 0° trajectory, we plotted 3 additional trajectories at 30° intervals and the relationship with the IJV and thyroid proximity was graded as following: 0=absent, 1=adjacent, and 2=crossing. The CCA tortuosity index was also analyzed for each vessel.

RESULTS

Analysis of 2800 trajectories across 100 CCAs showed that the IJV and thyroid were least encountered on the axial sections 2 cm above the clavicle, at 0° on the right (9 thyroids and 6 IJV), and at 90° on the left (0 Thyroids and 14 IJVs). The tortuosity index of the CCA was significantly lower above the clavicle than its entire length (P < 0.001).

CONCLUSIONS

DCP performed 2 cm above the clavicle at 0° on the right, and 90° on the left appears to minimize encounters with the IJV and thyroid gland, reducing potential complications. However, despite these findings, ultrasound guidance remains vital for DCP safety. Further focus on endovascular device safety in DCP is needed.

Hemiplegia in acute ischemic stroke: A comprehensive review of case studies and the role of intravenous thrombolysis and mechanical thrombectomy

Acute ischemic stroke is a significant health concern worldwide, often leading to long-term disability and decreased quality of life. Rapid and appropriate treatment is crucial for achieving optimal outcomes in these patients. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are two commonly used interventions for acute ischemic stroke, but their effectiveness in improving neurological symptoms and functional outcomes in patients with hemiplegia remains uncertain. The aim of this work was to evaluate the impact of IVT and MT within a 4.5-h time frame on patients with acute ischemic stroke and hemiplegia. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies that assessed the impact of IVT and MT within 4.5-h on hemiplegia in patients with an acute ischemic stroke were included. Data were extracted and analyzed to determine the overall effects of these interventions. Most included case reports indicate positive outcomes in terms of neurological symptom improvement and functional recovery in patients with hemiplegia after receiving IVT and MT within the specified time frame. However, the heterogeneity among the patients and the limited use of IVT due to contraindications posed challenges in determining the most effective treatment option. The findings from the included studies demonstrate that both interventions led to a decrease in National Institutes of Health Stroke Scale scores, indicating an improvement in neurological symptoms. The results highlight the beneficial effects of early thrombolytic interventions and MT on the neurological status and functional outcomes of patients with an acute ischemic stroke.

Direct carotid artery puncture for acute ischemic stroke: Local experience and systematic review

BACKGROUND

To establish surgical access during endovascular treatment of ischemic stroke, femoral artery puncture is most commonly performed followed by a small number of radial artery access procedures. However, there are few reports of carotid artery puncture.

METHODS

We report the case of an 87-year-old woman who was admitted to hospital with hemiplegia of the left limb and loss of consciousness for 40 min, accompanied by urinary incontinence. After complicated transfemoral and transradial attempts, the patient underwent emergency direct carotid artery puncture (DCAP) for the treatment of acute ischemic stroke. We reviewed the literature on this topic over a 7-year period (September 2014 to April 2022), including 202 patients with acute ischemic stroke who underwent emergency DCAP and endovascular surgery.

RESULTS

The average age of these patients was 80.5 years. The left DCAP accounted for 52.5% (106/202) of the cases. Local anesthesia was utilized in 33.9% (64/189) of the cases. Angio-Seal was utilized for closure in 53.7% (79/147) of the patients. About half (105/199) of the patients recovered or improved their limb function after DCAP. Postoperative complications were mainly neck hematoma and one of these patients died due to a fatal neck hematoma.

CONCLUSION

We describe the detailed procedure of the rare case of an emergency DCAP performed at our institution. DCAP provides an alternative treatment method in cases where thrombus removal access cannot be established through traditional methods.

Rescue carotid puncture for ischemic stroke treated by endovascular therapy: a multicentric analysis and systematic review

BACKGROUND

Endovascular therapy (EVT) for acute ischemic stroke (AIS) can be challenging in older patients with supra-aortic tortuosity. Rescue carotid puncture (RCP) can be an alternative in case of supra-aortic catheterization failure by femoral access, but data regarding RCP are scarce. We sought to investigate the feasibility, effectiveness and safety of RCP for AIS treated by EVT.

METHODS

Patients treated by EVT with RCP were included from January 2012 to December 2019 in the Endovascular Treatment in Ischemic Stroke (ETIS) multicentric registry. Main outcomes included reperfusion rates ( ≥ TICI2B), 3 month functional outcome (modified Rankin Scale) and 3 month mortality. We also performed an additional systematic review of the literature according to the PRISMA checklist to summarize previous studies on RCP.

RESULTS

25 patients treated by EVT with RCP were included from the ETIS registry. RCP mainly concerned elderly patients (median age 85 years, range 73-92) with supra-aortic tortuosity (n=16 (64%)). Intravenous thrombolysis (IVT) was used for nine patients (36%). Successful reperfusion was achieved in 64%, 87.5% of patients were dependent at 3 months, and 3 month mortality was 45.8%. The systematic review yielded comparable results. In pooled individual data, there was a shift toward better functional outcome in patients with successful reperfusion (median (IQR) 4 (2-6) vs 6 (4-6), p=0.011).

CONCLUSION

RCP mainly concerned elderly patients admitted for AIS with anterior LVO with supra-aortic tortuosity. The procedure seemed feasible, notably for patients treated with IVT, and led to significant reperfusion rates at the end of procedure, but with pronounced unfavorable outcomes at 3 months. RCP should be performed under general anesthesia to avoid life-threatening complications and ensure airways safety. Finally, RCP led to low rates of closure complications, emphasizing that this concern should not withhold RCP, if indicated.

Direct Common Carotid Artery Puncture: Rescue Mechanical Thrombectomy Strategy in Acute Ischemic Stroke

PURPOSE

In a minority of cases, the transfemoral approach cannot be performed due to unfavorable anatomical barriers. In such cases, direct common carotid artery puncture (DCCAP) is an important alternative for rescue mechanical thrombectomy. The purpose of this study was to evaluate the efficacy and safety of DCCAP in patients with an unaccessible femoral route for mechanical thrombectomy.

MATERIALS AND METHODS

This is a retrospective study using data in the Turkish Interventional Neurology Database recorded between January 2015 and April 2019. Twenty-five acute stroke patients treated with DCCAP were analyzed in this study. Among 25 cases with carotid puncture, 4 cases were excluded due to an aborted thrombectomy attempt resulting from unsuccessful sheath placement.

RESULTS

Patients had a mean age of 69±12 years. The average National Institutes of Health Stroke Scale score was 16±4. Successful revascularization (modified Thrombolysis In Cerebral Infarction 2b-3) rate was 86% (18/21), and 90-day good functional outcome rate (modified Rankin Scale 0-2) was 38% (8/21).

CONCLUSION

DCCAP is a rescue alternative for patients with unfavorable access via the transfemoral route. Timely switching to DCCAP is crucial in these cases.

Direct carotid puncture in acute ischaemic stroke intervention

Endovascular intervention for acute ischaemic stroke care is mostly performed in older patients, often with unfavourable aortic and supra-aortic anatomy, as well as cardiovascular comorbidities. A significant subset of them may benefit from transcervical access as the initial approach for mechanical thrombectomy. In fact, direct carotid artery puncture in these cases has the advantage to bypass the anatomical obstacles and achieve faster reperfusion. Caution is advised when common carotid artery access is pursued in order to avoid adverse events, including haematoma formation, iatrogenic arterial dissection and sheath kinking. In spite of potential complications, direct carotid puncture in acute ischaemic stroke intervention overcomes challenging angioarchitecture and may reduce the rate of poor clinical outcomes associated with delayed revascularisation in certain cases.