Carotid artery stenting with proximal embolic protection via the transbrachial approach: sheathless navigation of a 9-F balloon-guiding catheter.

PURPOSE: Transbrachial carotid artery stenting (TB-CAS) is performed as an alternative procedure for patients with hostile vascular anatomy of the aortic arch and aortic or peripheral artery disease. Proximal protection during TB-CAS is not generally feasible because a small size of the brachial artery may preclude using a large-diameter sheath introducer. We, herein present a novel method that enables proximal protection during TB-CAS by sheathless navigation of a 9-F balloon-guiding catheter equivalent to a 7-F sheath. METHODS: We analyzed eight consecutive patients who underwent TB-CAS with proximal protection using the sheathless method from April 2016 to June 2017. Relevant demographic, radiographic, and procedural features were retrospectively reviewed. RESULTS: We performed TB-CAS using our method for five patients with a bovine or type 3 aortic arch, for one patient with combined peripheral artery disease, and for two patients with a type 1 or 2 aortic arch. We successfully navigated the balloon-guiding catheter via the brachial artery and performed CAS under proximal flow control in all patients. However, we experienced kinking and exchange of the balloon-guiding catheter in one patient and a periprocedural thromboembolic event occurred. A pseudoaneurysm at the access site developed in one patient. CONCLUSION: TB-CAS with proximal embolic protection using the sheathless method is feasible and may provide an alternative approach in carefully selected patients who have difficult anatomy in the transfemoral approach and plaques with a high risk of distal embolization.

Successful carotid artery stenting of a dissected, highly tortuous internal carotid artery after straightening with a peripheral microguidewire.

Endovascular reconstruction for carotid artery dissection (CAD) involving a highly tortuous segment of the cervical internal carotid artery (ICA) is challenging because the tortuous ICA may preclude navigation of large-profile carotid stents. Successful recanalization using low-profile neurostents has been reported in small case series only. We herein describe two patients with CAD of a tortuous segment who were successfully treated with large-profile carotid stents after straightening the ICA with a stiff peripheral microguidewire. In Case 1, a 33-year-old man presented with steno-occlusive left CAD involving coiling of the cervical ICA and left M2 occlusion. We could not navigate a carotid stent through the tortuous segment of the ICA using a standard neuro-guidewire. A carotid stent was successfully deployed after straightening the tortuous ICA with a peripheral guidewire, and subsequent thrombectomy using a large-bore aspiration catheter for the occluded M2 branch resulted in recanalization. In Case 2, a 64-year-old man presented with right steno-occlusive CAD involving kinking of the cervical ICA. We successfully deployed two carotid stents after straightening the tortuous ICA with a peripheral guidewire. Stenting after straightening with a peripheral microguidewire is feasible and may provide a therapeutic option for CAD in patients with a highly tortuous ICA.

Iatrogenic Ascending Pharyngeal Artery Injury by Predilation Balloon Inflation During Carotid Artery Stenting with Flow Reversal.

BACKGROUND: The ascending pharyngeal artery (APA) may rarely arise from the common carotid artery bifurcation. We report an injury to the APA as an unusual complication of predilation balloon inflation during carotid artery stenting (CAS) with flow reversal. CASE DESCRIPTION: A 73-year-old man presented with symptomatic severe left cervical internal carotid artery stenosis. The left APA arose from the common carotid artery bifurcation. We performed CAS with flow reversal to decrease the risk of distal embolization. When we attempted to catheterize the internal carotid artery under roadmap guidance for predilation, we did not notice that the balloon catheters had advanced into the APA owing to the absence of an anterograde angiogram, and the APA was injured when the balloon catheters were inflated. CONCLUSIONS: Our case emphasizes the importance of performing a detailed anatomic assessment before CAS and ensuring adequate angiographic visualization during the procedure under flow reversal when the origin of the APA is in the vicinity of the origin of the internal carotid artery.