Download 5.Open cervical approach for carotid artery stenting

Open cervical approach for carotid
artery stenting
St. Anna Hospital Sofia
Cardiology department
Dr. V. Velchev
Tokuda Hospital Sofia
Vascular Surgery and Angiology Department
Assoc. Proff. V. Chervenkov, Dr. A. Daskalov
• In last decades, vascular surgery has been revolutionized by endovascular
techniques that allow percutaneous vascular intervention.
•
Advances in biomaterials and biotechnology had given a variety of lowprofile equipment and improved balloon and stent design.
•
Although the majority of carotid stenting procedures can be performed
using the retrograde femoral artery approach, there are some anatomical
variations of aortic arch and aortic arch branches which can make
retrograde carotid stent delivery nearly impossible.
“Unfavorable” anatomy
aortic arch
Bovine arch
Tortuosity
Absence of accessible common femoral artery
Abdominal aortic occlusion
Present Aorto-bifemoral bypass
Pulseless disease (Takayasu's arteritis)
Alternative Vascular access
•
Radial or brachial access: does not overcome a tortuous supra-aortic trunk
anatomy and only provides meaningful advantages for the right carotid artery. The
small caliber of the radial artery increases the risk of arterial injury.
•
Transseptal access: requires special skills and support and does not overcome the
challenges imposed by an unfavorable anatomy of the aortic arch and its branches.
•
Percutaneous transcervical CCA access: difficult access-site management after
sheath removal, especially in patients who require large guiding catheters and who
are treated with both antiplatelet and anticoagulant medications, despite of using
closure devices.
What to do if it is impossible to cannulate common carotid
artery ?
What to do if it is impossible to cannulate common carotid
artery ?
Carotid Endarterectomy
(CEA) ?
Limitations of CEA
• Patients with distal internal carotid artery lesions that are difficult to
access via endarterectomy (mandibular subluxation).
• Patients who have undergone radiation therapy to the cervical carotid
area.
• Patients who have previosly undergone ipsilateral CEA or other surgery in
this area.
• Patients with severe comorbidity.
Surgical exposure of the carotid arteryadvantages
• Major advantage of the transcervical surgical access with a carotid cut
down compared to transfemoral access is that the aortic arch is not
passed, which eliminates the risk of atheroembolization at the time of
catheter and wire navigation through the aortic arch and supra-aortic
trunks.
• Provides a safe access with surgical closure of artery puncture.
• In cases of retrograde CAS for stenosis of the proximal CCA there is a good
protection against embolism.
• Possible to perform under local anestesia.
Technique
The common carotid artery is exposed along a short segment just above
the clavicle on the side of the intended stent deployment and is held with
a vessel loop. From this point on the procedure is identical to a
percutaneous retrograde approach. Once the procedure is complete, a
surgical suture of the vessel wall is done and the wound is closed.
Case report
• 76-year-old male patient.
• Right hemispheric transient ischemic attacks
in past three months.
• Left hemispheric stroke two years ago.
• Risk factors: Diabetes mellitus type II,
Hypertension, Hyperlipaemia.
• Duplex: Occlusion of LICA, 40% stenosis of
RICA at the bifurcation, followed by a highgrade stenosis (85%) in submandibular area.
Initial angiography:
Occlusion of LICA
Stenosis of RICA
• RICA stenting procedure via transfemoral and left radial approach
failed due to anatomical reasons ( type III aortic arch).
• CEA was not acceptable because of submandibular location of highgrade stenotic lesion of RICA.
• A hybrid procedure was performed, combining surgical exposure of
the common carotid artery, followed by endoluminal stenting of
RICA.
Procedure
Passing the lesion with 0.014
guidewire and placing a
protection device:
Initial angio:
Procedure
After predilation with
3,5/22 mm balloon:
Releasing a Cristallo ideale
9/30mm:
Procedure
Result after
postdilation with a 4/25
balloon
Conclusions
• In patients who are unsuitable for transfemoral access due
to unfavorable aortic arch/supra-aortic trunk anatomy, a
direct transcervical approach with a carotid cut down can
be useful for the endovascular treatment of carotid artery
disease.
• This technique allows the achievement of hemostasis in a
controlled fashion at the end of the procedure despite the
use of anticoagulation. It is a safe and effective alternative
method in cases in which a distal arterial access cannot be
used.
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