Retrograde Carotid Stenting for Isolated Stenosis of the Proximal Common Carotid Artery-Case Report-

Symptomatic Common Carotid Artery Stenosis Managed With Carotid Endarterectomy

Extracranial carotid artery disease is typical at the carotid bifurcation and internal carotid artery (ICA) and is rarely symptomatic from isolated common carotid artery (CCA) stenosis. We present the case of a 60-year-old female patient who presented with a transient ischemic attack (TIA) with significant stenosis of the ipsilateral CCA only, without any involvement of the ICA or bifurcation. This was treated with carotid endarterectomy (CEA) with desirable postoperative outcomes; at up to six months postoperative follow-up, this patient had no recurrence of symptoms. We draw attention to the current gap in the literature with regard to a lack of specific guidelines for optimal evidence-based surgical treatment for this specific condition, with recent advances within certain vascular societies.

Stenting of the Common Carotid Artery Ostium: Balloon Catheter Lifting-Up Technique With a Gooseneck Snare

Endovascular revascularization of a stenotic lesion requires appropriate stent positioning. In particular, stenting of the common carotid artery (CCA) ostium makes it difficult to avoid proptosis into the aorta. Furthermore, the guiding catheter may become unstable during the stenting because of its position under the aortic arch. To resolve these problems, we performed antegrade stenting for a patient with a symptomatic stenotic left CCA ostium that was treated by lifting a balloon-guiding catheter with a gooseneck snare. Our patient was a 74-year-old man who presented to the hospital with main complaints of right hemiparesis and motor aphasia. A left cerebral infarction due to severe stenotic left CCA ostium was diagnosed. A CT perfusion study showed decreased cerebral blood flow in the left hemisphere. Stenting of the stenotic left CCA ostium was performed using an antegrade approach. A balloon-guiding catheter positioned under the aortic arch was inflated and lifted from the right brachiocephalic artery using a gooseneck snare. The guiding catheter was stabilized during stenting. This method is highly effective for stenting CCA ostium.

Surgical exposure of the carotid artery for endovascular interventional procedures

BACKGROUND

Transfemoral approach for endovascular interventions is not always possible in cases of unfavorable anatomy. We report our experience using a transcervical approach with carotid cut down and direct, controlled puncture of the carotid artery.

METHODS

Four patients underwent surgical exposure of the carotid artery for endovascular procedures. One patient had retrograde placement of a stent in the common carotid artery, and three patients had coiling of an intracranial aneurysm. After the endovascular procedure, the sheath was removed and the vessel was closed, under direct visualization.

RESULTS

The technique allowed access to extracranial and intracranial lesions. There were no access site complications. There were no access site-related cardiac, systemic, or neurologic events.

CONCLUSIONS

Transcervical access with surgical exposure of the carotid artery for direct and controlled vascular puncture is an effective alternative for endovascular extracranial and intracranial procedures in patients in whom the femoral route cannot be used.

Cerebral Protection During Retrograde Carotid Artery Stenting for Proximal Carotid Artery Stenosis-Technical Note-

Carotid artery stenting for carotid bifurcation stenosis usually uses the transfemoral approach. However, in patients with proximal common carotid artery (CCA) stenosis, the guiding catheter is difficult to introduce into the narrow origin of the CCA without risking cerebral embolization before activation of the protection device. A technique of cerebral protection by internal carotid artery (ICA) clamping with or without simultaneous external carotid artery (ECA) clamping was used to treat patients with proximal CCA stenosis by the retrograde direct carotid approach. The carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the stenosis. The ICA was clamped during angioplasty and stenting to avoid cerebral embolization. The ECA was clamped simultaneously if any extracranial-intracranial anastomosis was present. None of five patients treated with this technique experienced ischemic complications attributable to this technique.

Percutaneous reconstruction of the innominate bifurcation using the retrograde ‘kissing stents’ technique

INTRODUCTION

Obstructions of the supraaortic vessels are an important cause of morbidity associated with a variety of symptoms. Percutaneous transluminal angioplasty has evolved as an effective and safe treatment modality for occlusive lesions of the supraaortic vessels. However, the endovascular management of an innominate bifurcation has not previously been reported.

METHODS

A 53-year-old female with a history of systematic hypertension, diabetes mellitus and hypercholesterolemia presented with left hemiparesis and dysarthria. Angiography of the innominate artery showed a stenosis of the innominate bifurcation.

RESULTS

The lesion was successfully treated using the retrograde kissing stent technique via a brachial approach and an exposed direct carotid approach.

CONCLUSION

The retrograde kissing stent technique for the treatment of a stenosis of the innominate bifurcation was found to be a safe and effective alternative to conventional surgery.