Combined surgical and endovascular approach to treat symptomatic in-stent occlusion of the left common carotid artery origin

Technical note

Restricted access

Symptomatic occlusive lesions at the origins of the supra-aortic vessels pose challenges for treatment. Endovascular angioplasty and stent placement via the transfemoral approach is possible, but obtaining a stable position for the guide catheter via this approach is technically difficult. The authors describe the case of a 56-year-old man presenting with symptomatic occlusion of a previously placed stent at the origin of the left common carotid artery (CCA). An endovascular revascularization of the left CCA was planned. However, the absence of a lumen proximal to the stent prevented stable placement of a guide catheter via the transfemoral route. Consequently, the authors used a combined surgical and endovascular approach to gain access to the lesion. The left CCA was exposed surgically distal to the occlusion and clamped just proximal to its bifurcation to preserve flow from the external to the internal carotid artery (ICA) and to prevent embolism into the ICA. A wire was passed retrograde through the occlusive lesion and then was subsequently advanced proximally into the femoral sheath. This allowed transfemoral advancement of the appropriate endovascular devices to perform an angioplasty and placement of a stent. The patient remained neurologically stable, and postoperative studies showed improvement in cerebral perfusion. This case demonstrates the feasibility of distal-to-proximal stent delivery with a combined endovascular and surgical approach.

Abbreviations used in this paper: ACA = anterior cerebral artery; AP = anteroposterior; CCA = common carotid artery; ECA = external carotid artery; ICA = internal carotid artery; MCA = middle cerebral artery; NIHSS = National Institutes of Health Stroke Scale; OA = occipital artery.

Article Information

Address correspondence to: Qaisar A. Shah, M.D., Department of Neurology, MMC 295, 420 Delaware Street Southeast, University of Minnesota, Minneapolis, Minnesota 55455. email: qaisarshah@gmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Preoperative angiographic studies. A: Aortic arch, left anterior oblique view, revealing complete occlusion of the left CCA at its origin (arrow). B: Left subclavian artery (A.), lateral view. Arterial phase demonstrating left vertebral artery and left ascending cervical artery. C: Left subclavian artery, lateral view. Midarterial phase demonstrating anastomosis between ascending cervical artery and left OA (circle). D: Left subclavian artery, lateral view. Late arterial phase demonstrating retrograde filling of left ECA and left ICA.

  • View in gallery

    Intraoperative angiographic studies. A: Unsubtracted, AP view, demonstrating a 0.035-in exchange-length guidewire (arrowhead) passing through the occluded stent (arrow) at the origin of the left CCA. B: Unsubtracted, AP view. The guidewire is trapped with a microsnare (arrow). C: Unsubtracted, AP view. A balloon catheter is inflated within the stent (arrow).

  • View in gallery

    Postoperative angiographic studies. A: Left CCA, AP view. Good flow through the recanalized left CCA (arrowheads) and high-grade stenosis distal to the stent (arrow) are demonstrated. B: Left CCA, AP view. The second stent was placed, which overlapped the original one (arrows), with a proximal marker within the first stent and distally covering the stenosis (arrowheads).

  • View in gallery

    Follow-up angiographic studies. A: Left CCA, intracranial AP view. Good flow through ICA, left ACA, and cross-filling through the anterior communicating artery are demonstrated. There is chronic occlusion of the left MCA (arrow). B: Left CCA, intracranial AP view. Midarterial phase, demonstrating leptomeningeal collateral vessels through branches of ECA with MCA (circle).

References

  • 1

    Allie DEHebert CJLirtzman MDWyatt CHKhan MHKhan MA: Intraoperative innominate and common carotid intervention combined with carotid endarterectomy: a “true” endovascular surgical approach. J Endovasc Ther 11:2582622004

    • Search Google Scholar
    • Export Citation
  • 2

    Arko FRBuckley CJLee SDManning LGPatterson DE: Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels. J Cardiovasc Surg (Torino) 41:7377422000

    • Search Google Scholar
    • Export Citation
  • 3

    Byrne JDarling RC IIIRoddy SPMehta MPaty PSKreienberg PB: Long term outcome for extra-anatomic arch reconstruction. An analysis of 143 procedures. Eur J Vasc Endovasc Surg 34:4444502007

    • Search Google Scholar
    • Export Citation
  • 4

    Crawford ESDe Bakey MEMorris GC JrHowell JF: Surgical treatment of occlusion of the innominate, common carotid, and subclavian arteries: a 10 year experience. Surgery 65:17311969

    • Search Google Scholar
    • Export Citation
  • 5

    Criado FJTwena M: Techniques for endovascular recanalization of supra-aortic trunks. J Endovasc Surg 3:4054131996

  • 6

    Grego FFrigatti PLepidi SBonvini SAmista PDeriu GP: Synchronous carotid endarterectomy and retrograde endovascular treatment of brachiocephalic or common carotid artery stenosis. Eur J Vasc Endovasc Surg 26:3923952003

    • Search Google Scholar
    • Export Citation
  • 7

    Levien LJBenn CAVeller MGFritz VU: Retrograde balloon angioplasty of brachiocephalic or common carotid artery stenoses at the time of carotid endarterectomy. Eur J Vasc Endovasc Surg 15:5215271998

    • Search Google Scholar
    • Export Citation
  • 8

    Macierewicz JArmon MPCleveland TJGaines PABeard JD: Carotid endarterectomy combined with proximal stenting for multilevel disease. Eur J Vasc Endovasc Surg 20:5725752000

    • Search Google Scholar
    • Export Citation
  • 9

    Modarai BAli TDourado RReidy JFTaylor PRBurnand KG: Comparison of extra-anatomic bypass grafting with angioplasty for atherosclerotic disease of the supra-aortic trunks. Br J Surg 91:145314572004

    • Search Google Scholar
    • Export Citation
  • 10

    Payne DAHayes PDBolia AFishwick GBell PRNaylor AR: Cerebral protection during open retrograde angioplasty/stenting of common carotid and innominate artery stenoses. Br J Surg 93:1871902006

    • Search Google Scholar
    • Export Citation
  • 11

    Shumacker HB JrIsch JHJolly WWFitzgerald EB: The management of stenotic and obstructive lesions of the aortic arch branches. Am J Surg 133:3513601977

    • Search Google Scholar
    • Export Citation
  • 12

    Takach TJDuncan JMLivesay JJKrajcer ZCervera RDGregoric ID: Brachiocephalic reconstruction II: operative and endovascular management of single-vessel disease. J Vasc Surg 42:55612005

    • Search Google Scholar
    • Export Citation
  • 13

    Takach TJReul GJCooley DADuncan JMLivesay JJGregoric ID: Brachiocephalic reconstruction I: operative and long-term results for complex disease. J Vasc Surg 42:47542005

    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 60 60 3
Full Text Views 49 35 0
PDF Downloads 35 33 0
EPUB Downloads 0 0 0

PubMed

Google Scholar