Comparison of a Sheathless Transradial Access With Looping Technique and Transbrachial Access for Carotid Artery Stenting

PURPOSE

To evaluate the feasibility and safety of sheathless transradial access (TRA) with the looping technique for carotid artery stenting (CAS) compared with the transbrachial approach (TBA).

METHODS

Among 99 symptomatic patients with a history of transient ischemic attack (TIA) or stroke, 38 patients (mean age 69±10 years; 28 men) with documented internal carotid artery stenosis were selected for CAS via a sheathless TRA and compared with 61 patients who received CAS via the brachial artery. Routine assessments of radial artery patency using duplex ultrasound and clinical follow-up were performed at 1, 6, and 12 months.

RESULTS

The sheathless TRA technique offered 100% procedure success; only 1 patient in the sheathless TRA group and 2 patients in the TBA group experienced TIAs during the procedure. There were no major complications (major stroke or 30 day in-hospital death) in either group or radial access site complications. The incidence of radial artery occlusion in the sheathless TRA CAS group was 9% (3/33) at 1 year (5 patients died unrelated to the procedure).

CONCLUSION

The sheathless TRA with looping technique may be an alternative to transbrachial access for CAS in patients who have small radial arteries and are unsuitable for the transfemoral approach.

Complex carotid stenting using a coronary technique

PURPOSE

To report the utility of a coronary technique to facilitate carotid stenting in patients with difficult arch anatomies.

TECHNIQUE

When confronted with challenging arch anatomy that prevents engaging the common carotid artery (CCA) with the guiding sheath using standard techniques, an 8-F left Amplatz guiding catheter (AL1) is placed at the origin of the innominate artery. A 0.014-inch coronary guidewire is advanced into the external carotid artery (ECA), and a small monorail coronary balloon is inflated in a small branch of the ECA. The balloon/guidewire combination facilitates maneuvering a 0.035-inch Amplatz super-stiff guidewire through the ECA and then advancing the guiding catheter into the CCA.

CONCLUSION

This anchoring technique can be a helpful method for cannulating the CCA in patients with a complex arch when the ECA is patent.

Transcervical carotid stenting with flow reversal for neuroprotection: technique, results, advantages, and limitations

Carotid angioplasty and stenting are progressively earning a role as a less invasive alternative in the treatment of carotid occlusive disease. The most common approach for carotid artery stenting involves transfemoral access and use of a filter or balloon device for neuroprotection. This approach has limitations related to both the site of access and the method of neuroprotection. Specifically, an aortoiliac segment with advanced occlusive or aneurysmal disease or an anatomically unfavorable or atheromatous arch and arch branches can significantly limit the safety of the retrograde transfemoral pathway to the carotid bifurcation. Additionally, data provided by the use of transcranial Doppler monitoring and diffusion-weighted magnetic resonance imaging in patients undergoing filter- or balloon-protected carotid artery stenting demonstrate that currently available devices are associated with a considerable incidence of cerebral embolization. To address these limitations, we, along with others, have employed a direct transcervical approach for carotid artery stenting that incorporates the principle of flow reversal for neuroprotection. The technique bypasses all of the anatomic limitations of transfemoral access and simplifies the application of flow reversal, which is one of the safest neuroprotection techniques. The purpose of this review is to describe our method of transcervical carotid artery stenting, review the accumulating outcomes data, and discuss the clinical advantages of and indications for this increasingly popular technique.

Carotid stenting with distal-balloon protection via the transbrachial approach

PURPOSE

To document the feasibility of brachial artery access for carotid stenting with distal-balloon protection of the internal carotid artery (ICA).

TECHNIQUE

Via percutaneous access to the brachial artery, a large double-curve catheter is advanced into the aortic arch over a hydrophilic guidewire to cannulate the left common carotid artery. Following sheath exchange, a GuardWire distal-protection balloon is positioned within the left ICA distal to the stenosis. The lesion is dilated, followed by deployment and dilation of a self-expanding stent. Transcranial Doppler monitoring shows only scarce microembolic signals during the procedure.

CONCLUSIONS

Carotid stenting with distal balloon protection via the brachial artery appears feasible as an alternative to standard femoral access.