Stent placement in common carotid and internal carotid artery stenoses with use of an open transcervical approach in a patient with previous endarterectomy

Results of carotid artery stenting with transcervical access

OBJECTIVE

Carotid artery stenting (CAS) is usually performed with femoral access; however, this access may be impeded by anatomic limitations. Moreover, many embolic events happen during aortic arch catheterization. To overcome these problems, transcervical access to the carotid artery can be used as an alternative approach for CAS.

METHODS

An electronic search of the literature using PubMed was performed. All studies reporting the results of CAS using the transcervical approach were retrieved and analyzed.

RESULTS

The analysis included 12 studies reporting the results of 739 CAS procedures performed in 722 patients (mean age, 75.5 years). Of 533 lesions reported, 235 (44%) were symptomatic, with no data regarding symptomatic status available for 206 lesions. Two techniques were used: direct CAS with transcervical access (filter protected or unprotected) in 250 patients and CAS with transcervical access under reversed flow (with arteriovenous shunt in most cases) in 489 patients. Local anesthesia was used in 464 of 739 procedures (63%), and the remaining were performed under general anesthesia or cervical block. Technical success was 96.3% for 579 procedures with available data (558 successful procedures and 21 failures: inability to cross the lesion, 10; dissection, 5; failure of predilatation, 1; stent thrombosis, 1; patient agitation, 1; and no data, 3). The incidence of conversion to open repair was 3.0% (20 of 579 procedures: 18 carotid endarterectomies and two common carotid-internal carotid bypass grafts). Stroke occurred in eight patients (two fatal) and a fatal myocardial infarction in one patient. The incidence of stroke, myocardial infarction, and death was 1.1%, 0.14%, and 0.41%, respectively. The incidence of stroke was 1.2% (3 of 250) in direct CAS with transcervical access and 1.02% (5 of 489) in CAS under reversed flow (P > .05). Transient ischemic attack occurred in 20 patients (2.7%). Local complications were encountered in 17 of 579 CAS (2.9%), comprising 15 hematomas and two patients with transient laryngeal palsy.

CONCLUSIONS

CAS with the transcervical approach is a safe procedure with low incidence of stroke and complications. It can be used as an alternative to femoral access in patients with unfavorable aortoiliac or aortic arch anatomy.

Intraoperative Stenting for Brachiocephalic and Carotid Artery Stenosis

OBJECTIVE

Endovascular stenting is an alternative treatment for brachiocephalic artery stenosis, replacing standard surgical approaches such as carotid endarterectomy. However, a percutaneous approach may be difficult because various conditions such as severe arteriosclerosis of iliac or femoral arteries and aortic disease. We report our experience with intraoperative stenting for these lesions, presenting indications, strategy, and results.

METHODS

Seven patients underwent intraoperative stent placement via an open cervical approach. The sites of lesions included 1 innominate artery, 1 common carotid artery, and 5 cervical carotid arteries. Stenting was performed with a sheath introducer placed through a surgically exposed common carotid artery via a small skin incision or common carotid artery exposed for simultaneously performed carotid endarterectomy. Distal protection was used in 6 patients with an endovascular protective balloon or external clamping with forceps.

RESULTS

Sufficient dilation of stenosis was obtained in all cases. No complications such as transient ischemic attack, cerebral infarction, and hyperperfusion were encountered. Wound hematoma was not experienced despite perioperative antiplatelet therapy and heparinization during the procedure. Angiographic follow-up over 1 year showed no restenosis in 5 available patients.

CONCLUSION

Intraoperative stenting may be an excellent alternative for patients in whom both direct surgical approach and standard percutaneous endovascular approach are not possible.

Stent-graft treatment of late stenosis of the left common carotid artery following thoracic graft placement

We report the case of a patient with subtotal occlusion of the origin of the left common carotid artery (CCA) following thoracic graft placement. Retrograde endovascular placement of a stent-graft by minimal cervical access was undertaken to repair the occlusive lesion of the left CCA and prevent future complications of endoluminal thoracic reconstruction. The retrograde endovascular repair of CCA lesions, as other authors have already suggested, may be the treatment of choice in "high-surgical-risk" patients. In these cases where the ostium of supra-aortic trunks is compromised following thoracic aorta stent-graft migration, endoluminal placement of a stent-graft in the CCA can guarantee both maintenance of carotid flow and thoracic stent-graft fixation.

Access site complications with carotid angioplasty and stenting

BACKGROUND

Carotid angioplasty and stenting is a relatively new therapeutic alternative to CEA for treatment of carotid stenosis. The percutaneous transfemoral approach, the standard technique for angioplasty and stent deployment, may not be feasible in all patients. We present our experience with access site complications that occurred with CAS.

METHODS

One hundred thirty-two CAS procedures were performed at our institution in the past 5 years for symptomatic (62.1%) or asymptomatic (37.9%) carotid stenosis. Mean age of patients was 70.72 +/- 6.53 years and the mean degree of stenosis of the treated carotids was 80.74% +/- 11.83%. The transfemoral approach was the access route in 126 CAS, the transbrachial approach was used in 2 CAS procedures, and direct carotid exposure was used in 5 patients.

RESULTS

All CAS procedures were done successfully; 4 (3%) access site complications were detected, 3 (2.4%) groin hematomas with transfemoral approach and 1 hematoma on the left side of the neck, in patients treated with direct carotid cutdown. Surgical repair of FSA was successfully performed for the patients with groin hematoma, whereas surgical wound exploration in the neck for the remaining patient revealed no identifiable cause. All patients received blood transfusion for correction of associated hypovolemia or hemorrhagic anemia. No patients had experienced access site-related additional cardiac, systemic, or neurologic events.

CONCLUSIONS

The authors' experience demonstrates that access site complications are rare events with CAS despite the large diameter of implantable devices and liberal anticoagulant and antiplatelet therapy. Transbrachial and direct carotid approaches are relatively safe, accepted alternatives in the setting of contraindicated femoral access.

Direct access to the carotid circulation by cut down for endovascular neuro-interventions

BACKGROUND

Not all vascular lesions of the brain that are amenable to endovascular treatment are safely accessible via the transfemoral route. We describe our technique of carotid cut down for endovascular access and present a couple of illustrative cases. The increasing number of neurosurgeons performing endovascular procedures, or collaborating with interventional neuroradiologists, suggests that this technique should be revived.

METHODS

Through a small transverse neck incision at the level of the thyroid cartilage, the CCA, ICA, and external carotid artery are exposed. After obtaining vascular control with vessel loupes, a purse-string suture is placed in the CCA. Puncture of the artery in the center of the purse string is followed by navigation of a wire, and then a sheath, into the ICA. The neurointervention is then carried out. At the conclusion of the procedure, the sheath is removed from the CCA and the purse string tied to secure the artery.

RESULTS

This technique has allowed us to successfully access the intracranial circulation in 6 patients with challenging anatomy. We present here 2 of the original cases leading to our increasing use of this technique.

CONCLUSION

Carotid cut down for direct puncture of the CCA is a viable option to gain access to the intracranial circulation when the transfemoral route seems difficult or dangerous.

Technical challenges in a program of carotid artery stenting

OBJECTIVES

Successful carotid artery stenting (CAS) involves gaining access to the common carotid artery, characterizing and crossing the lesion, deploying an anti-embolic device and stent, and retrieving the anti-embolic device. These steps are critical determinants of the complexity of the procedure. The frequency with which technical challenges are encountered during CAS is ill-defined. The purpose of this investigation was to review the incidence and types of technical challenges encountered during CAS and determine their effect on outcome.

METHODS

Data were prospectively collected for 194 consecutive CAS procedures (177 patients) and separated into group 1, standard CAS technique, and group 2, procedures with technical challenges requiring modifications to the technique. Technical challenges were defined as difficult femoral arterial access (aortoiliac occlusive disease), complex aortic arch anatomy (elongated or bovine arch, deep takeoff of the innominate artery, tandem stenoses (CCA, innominate artery), difficult internal carotid artery anatomy (tortuosity, high-grade stenosis), and circumferential internal carotid artery calcification. The incidence of technical challenges, types of technical modifications required, and effect on outcomes were determined.

RESULTS

Fifty technically challenging situations (26%) were encountered in 194 CAS procedures (group 2), which required advanced technical skills. Standard methods were used in the other 144 procedures (group 1, 74%). No significant differences in 30-day stroke and death rates were noted between the groups (group 1, 3.1%; group 2, 2.0%; P = .564).

CONCLUSIONS

Twenty-six percent of the procedures required a modification in the standard technique for successful CAS. Circumferential calcification and severe tortuosity continue to be relative contraindications to CAS. Recognition of these technical challenges and increasing facility with the methods to manage them will enable expanded use of CAS without increased morbidity and mortality.