Transcervical approach for carotid artery stenting without reversal flow

Patient:

• A 54-year-old woman
• Main complaint: right hemiparesis
• Uncontrolled hypertension for 5 years
• Minor ischemic stroke with right hemiparesis 1 month ago
• No history of diabetes, heart disease, stroke, transient ischemic attack, thromboembolic or other vascular diseases

Physical examination:

• Blood pressure: 120/80 mmHg
• Heart rate: 90 bpm
• Respiratory rate: 20 times/min
• Blood sugar: 111.7 mg/dl.
• Other test values are normal

3 Tesla brain magnetic resonance imaging (MRI) revealed hyperintense lesions on the left hemisphere affected by severe stenosis of the ipsilateral internal carotid artery (Figure 1).

Figure 1: first cerebral MRI - A) hyperintense lesions on the left hemisphere (blue arrow); B) Severe stenosis of the ipsilateral internal carotid artery (green arrow).

Treatment plan:

• Suitable for digital subtraction angiography (DSA).
• Tortuous type III aortic arch and left common carotid artery

Figure 2: first endovascular therapy - A) tortuous type III aortic arch approached by 5F IMPRESS^® Simmons 2 Catheter (Merit Medical) (blue arrow); B) tortuous common carotid artery (red arrow); C) perpendicular origin with severe internal carotid artery stenosis (yellow arrow);

D) angioplasty (green arrow); E) restenosis of the internal carotid artery (white arrow).

• Carotid artery stenting failure
• From hemiparesis to hemiplegia
• MRI showed that the left hemisphere had more hyperintense lesions than on the first MRI, and a near occlusion of the left internal carotid artery

Treatment plan

Figure 3: second cerebral MRI - A) more hyperintense lesions on the left hemisphere than on the first MRI (blue arrow); B) near occlusion of the ipsilateral internal carotid artery (yellow arrow).

Change to transcervical access to perform stenting.

Figure 4: A) exposure of common carotid artery (blue arrow); B) 8F sheath introduced into common carotid artery (yellow arrow).

Diagram of transcervical carotid flow reversal technique: A) flow reversal from the common carotid artery to the internal jugular vein [6]; B) flow reversal from the common carotid artery to the femoral vein [7].

A) Near occlusion of the internal carotid artery (blue arrow); B) Microwire advanced into petrous segment of internal carotid artery (red arrow); C) First angioplasty;

D) Unsheathing the first stent (yellow arrow); E) Angiography after the first stent; F) Deployment of the second stent (white arrow)

G) Angioplasty after in-stent restenosis (green arrow); H, I) Left anterior circulation after carotid stenting in the lateral and anteroposterior planes, respectively.

• Recanalization was successful with TICI 3.
• There were no procedure-related complications after revascularisation.
• mRS 1 at 3 months after discharge.

Discussion:

• Transfemoral carotid artery stenting is the popular treatment for high-risk patients with severe carotid stenosis.
• Transcervical access may also be an alternative option, with:
  • either arterial tortuosity
  • or a reduction in the periprocedural thromboembolic risk.