564362
research-article2014
JETXXX10.1177/1526602814564362Journal of Endovascular TherapyBergeron
Technical Note
Direct Percutaneous Carotid Access for Carotid Angioplasty and Stenting
Journal of Endovascular Therapy 2015, Vol. 22(1) 135–138 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602814564362 www.jevt.org
Patrice Bergeron, MD1
Abstract Purpose: To describe a direct percutaneous carotid access technique for carotid artery stenting (CAS) that circumvents the potential for embolization that can occur during catheter manipulation in the aortic arch during femoral access. Technique: After inducing anesthesia, an ultrasound transducer is placed at the base of the neck above the clavicle. A 21-G, 7-cm needle from a micropuncture introducer is used for single-wall puncture of the common carotid artery (CCA). A 0.018-inch guidewire is inserted into the needle for placement of a 4-F, 10-cm introducer. After placing a 0.035-inch angled guidewire in the external carotid artery, the 4-F introducer is exchanged for the closure device sheath (preclose technique). A regular 6-F introducer is then placed inside the closure device sheath, and a low dose (2000 units) of heparin is administered for the brief CAS procedure, which is performed under cerebral protection. After a successful procedure is confirmed, the protection device is retrieved, and the closure device is applied to seal the puncture. Conclusion: This approach has a low rate of neurological and access site complications. Percutaneous direct carotid access could extend the indications for CAS to include difficult anatomies, high-risk patients, and certain emergent situations that warrant easy and rapid access to the CCA. Keywords carotid stenosis, carotid angioplasty, carotid stent, vascular closure device, direct cervical carotid puncture, ultrasound guidance, common carotid artery, cerebral protection Transfemoral access has long been the route of choice for carotid artery stenting (CAS).1,2 However, in difficult aortic arch anatomies (eg, gothic and bovine arches, tortuous carotid arteries, and shaggy or aneurysmal aortas), the need for arch manipulations increases the risk of embolization to the cerebral hemispheres. Facing these challenges, interventionists have developed alternative routes over the years.2–5 Among these approaches, direct common carotid artery (CCA) access has advocates. Some opt for a small cutdown, while we continue to pursue percutaneous access using low-profile introducer sheaths and low doses of heparin, which has resulted in excellent outcomes without significant access complications.6,7 The expected benefits of percutaneous direct carotid access are saving time and contrast and avoiding embolization from the aortic arch. Recently, several reports8–10 have emphasized the safety of direct carotid access for CAS, with a reduced number of new brain lesions on diffusionweighted imaging compared with femoral access. Looking to the recent trials comparing carotid endarterectomy (CEA) and CAS,11,12 there was no difference in terms of stroke/ death risk, but CEA increased the risk of myocardial infarction while CAS increased the risk of transient ischemic
attack (TIA). Reducing the number of TIAs might make CAS equivalent or better than CEA. The direct carotid access is one method of reducing the TIA risk by circumventing catheter manipulations in the aortic arch. This note describes a safe approach for CAS under direct carotid access that eliminates the risk of embolization that can occur during device navigation in the arch from the femoral route.
Technique Carotid artery stenting via a direct carotid access is undertaken using a micropuncture introducer set (Cook, Bloomington, IN, USA) and ultrasound guidance to ensure single wall puncture of the CCA. An ultrasound-guided puncture is advisable for anticoagulated patients, obese patients 1
Hôpital Privé Résidence du Parc, Marseille, France
Corresponding Author: Patrice Bergeron, Department of Thoracic and Cardiovascular Surgery, Hôpital Privé Résidence du Parc, 10 rue Gaston Berger, Marseille 13010, France. Email: [email protected]
136
Journal of Endovascular Therapy 22(1)
Figure 1. (A) Puncture of the common carotid artery (CCA) under ultrasound guidance. (B) Longitudinal view of the CCA with a guidewire inserted. (C) Placement of a 4-F introducer for delivery of the 0.035-inch guidewire to the external carotid artery. (D) Exchange of the 4-F introducer for the closure device sheath during the preclose technique. (E) Placement of a regular 6-F introducer in the closure device sheath, (F) which is then sutured to the skin. (G) Final appearance of the puncture after closure device application.
with reduced carotid pulsatility, low bifurcations requiring a very proximal puncture, and a frozen neck. The patient’s neck is extended with a cushion under the shoulders, and the C-arm is placed in a profile view. After establishing local or general anesthesia, the ultrasound transducer is placed at the base of the neck above the clavicle (Figure 1A), and a 21-G, 7-cm needle from a micropuncture introducer set (Cook Inc) is directed to the CCA parallel or perpendicular to the probe. A transverse or longitudinal view of the CCA (Figure 1B) is displayed on the screen showing the single-wall puncture. After carotid puncture, dye is injected to determine that there is enough room from the tip of the sheath to the carotid bifurcation for deploying the stent across the bifurcation and out of the sheath. If the puncture needs to be repeated without ultrasound guidance, a roadmap can be obtained by injecting contrast through the needle after placing the C-arm in an anteroposterior view. A 0.018-inch, 40-cm long guidewire is inserted into the needle for placement of a 4-F, 10-cm introducer (Figure 1C). The first angiogram is taken in a profile view. A 0.035inch angled guidewire is placed in the external carotid artery under roadmapping. The 4-F introducer is exchanged for the closure device sheath (Figure D1) not too far into the CCA (~1 cm checked on the roadmap). A preclose technique is recommended to avoid guidewire manipulations after stenting. A regular 6-F introducer is placed in the closure device sheath (Figure 1E); its position is checked by contrast injection and then the closure device sheath is fixed to the skin using 2 stitches (Figure 1F). A low dose of heparin (2000 units) is administered as the procedure is short.
Carotid artery stenting is performed as described elsewhere.13 A 0.014-inch guidewire is placed across the stenosis and a cerebral protection device of the operator’s choice is deployed. Stent placement and dilation (pre/post at the operator’s discretion) are followed by completion angiography at the bifurcation and brain levels. The protection device is retrieved, protamine is administered to reverse the heparin, and the closure device is applied to seal the puncture (Figure 1G).
Discussion Our group has performed over 300 CAS procedures via direct cervical access. The initial CAS cohort treated from December 1992 was reported in 2009.14 Among the 461 CAS procedures performed out of >2000 carotid procedures (~100/year), 254 were from a direct carotid access (routine use of a protection device began in 1999). In this subgroup, 2 patients presented with a TIA, 1 patient developed a major stroke from hyperperfusion syndrome (residual deficit limited to the right arm), and 1 patient developed monocular blindness. The stroke rate was 0.8%. No nerve palsy was observed. One cervical hematoma without lifethreatening complication was observed and resolved spontaneously without surgery, but in several other cases, a diffuse hematoma developed under the skin and was spontaneously reabsorbed. These may have been due to additional puncture of the CCA or excessive anticoagulation. Since 2013, we have used ultrasound-guided puncture and a closing device in the 52 patients (37 men; mean age 70.6 years, range 38–102) undergoing direct CCA access.
137
Bergeron All patients were taking clopidogrel (75 mg/d) or received a 300-mg loading dose the day before the procedure. All direct carotid access procedures were performed percutaneously with no need for cutdown, and a closure device was used for all. No death, stroke, TIA, nerve palsy, or cardiac events occurred in this series of patients undergoing CAS via percutaneous direct carotid access.
Technical Considerations Patients are selected for direct cervical access according to risk factors and anatomy. 1. Advanced age is traditionally considered high risk for CAS based on trial data11,12,15,16 that suggested a threshold of 70 years beyond which CEA is safer. We argue that elderly patients benefit from a less invasive technique and associated shorter hospitalization. Moreover, based on our experience, we believe that the increased risk of embolization is related to crossing the aortic arch in this population with advanced aortic disease.17 We opt for cervical access CAS in patients >70 years old if the arch is diseased and tortuous or in cases of incomplete arch imaging. 2. Recurrent stenosis after endarterectomy or radical neck surgery and postradiation stenosis are recognized indications for CAS.18,19 In some of these patients, we have performed cervical access, as the CCA is usually right under the skin, fixed by the scar tissue, and easily compressed. 3. Arch abnormality or disease that requires a complex procedure with several arch manipulations should be approached via a cervical access. The risk of contralateral or posterior brain embolization resulting from arch manipulations20 is eliminated with direct carotid access. Experienced and skilled operators will argue that the use of certain tools makes femoral access easy. However, we all recognize the increased time and risk associated with navigating arch anomalies (limiting the time to access the CCA to 15 or 20 minutes is recommended). In situations where a rapid procedure is advised, the direct carotid access is beneficial. 4. Technical failures in direct carotid stenting are not related to tortuosities but to difficulty crossing tight and calcified stenosis. As such, arteries with severe calcification exceeding 50% of the lumen circumference are not suitable for CAS. Ultrasound guidance is the best option when the equipment is available as it provides safe control of the puncture. There is a learning curve, and the first use of ultrasound
guidance can be done at the groin level. Ten cases at least are recommended to master the technique and start feeling comfortable with it. In our early experience, we closed the direct carotid access site using manual compression for at least 10 minutes. This approach was feasible and safe under the following conditions: the heparin dose was reduced from 5000 units for femoral access to 2000 units for cervical access procedures, and protamine was used to reverse the effects of heparin. The time saved by the direct carotid access approach allowed the lower heparin dose to cover the entire CAS procedure. We used a small introducer sheath, usually 6-F, and avoided making a double-wall puncture or multiple attempts at puncture. After a large experience using a closing device at the groin, we began successfully using it for the carotid application. We typically use Abbott’s StarClose device, which utilizes an adventitial nitinol clip providing 360° tissue apposition. We prefer this device over intraluminal closure devices that use anchors. By placing the device’s introducer at the beginning of the procedure, there is no need to place a guidewire across the stent. The closing device is advanced and the nitinol clip is delivered on the adventitia, securing the access. In the area of brain protection from embolization, it appears that blood flow reversal compares favorably to filter protection.21 The reverse flow technique can be used safely as a protective mechanism during local or general anesthesia provided the stump pressure is recorded, as we do during surgery. Combining direct carotid access with flow reversal might be the better option for CAS. A safe percutaneous approach with this protective device would considerably simplify the procedure. In our experience, this approach has never failed, and we have observed no complications related to stationary or reversed flow. We have performed percutaneous carotid access CAS under general anesthesia in most patients because it is comfortable for the patient and the operator and helps when using the roadmapping technique. The use of general anesthesia during direct carotid access CAS is not mandatory, and some interventionists perform direct carotid access with a cutdown and reverse flow protection under local anesthesia. There is no trial comparing local and general anesthesia for CAS as the GALA trial22 did for carotid surgery. GALA showed no difference in the proportion of patients with stroke, myocardial infarction, or death between general or local anesthesia in a large population. We opt for general anesthesia as we do for surgery, although we used local anesthesia in a previous surgical experience for high-risk patients before the advent of CAS.23
Conclusion Our experience suggests that percutaneous direct carotid access can be used safely and effectively for CAS, perhaps
138 even in patients with difficult anatomies, at high surgical risk, or in certain emergent situations that warrant easy and rapid access to the carotid artery. Acknowledgments The author wishes to thank Laurie LaRusso, MS, ELS, and Pierre Saint Girons for editorial assistance.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Diethrich EB, Ndiaye M, Reid DB. Stenting in the carotid artery: initial experience in 110 patients. J Endovasc Surg. 1996;3:42–62. 2. Diethrich EB, Marx P, Wrasper R, et al. Percutaneous techniques for endoluminal carotid interventions. J Endovasc Surg. 1996;3:182–202. 3. Al-Mubarak N, Vitek JJ, Iyer SS, et al. Carotid stenting with distal-balloon protection via the transbrachial approach. J Endovasc Ther. 2001;8:570–574. 4. Stella N, Palombo G, Filippi F, et al. Endovascular treatment of common carotid artery dissection via the superficial temporal artery. J Endovasc Ther. 2010;17:569–573. 5. Montorsi P, Galli S, Ravagnani PM, et al. Carotid artery stenting in patients with left ICA stenosis and bovine aortic arch: a single-center experience in 60 consecutive patients treated via the right radial or brachial approach. J Endovasc Ther. 2014;21:127–136. 6. Alessandri C, Bergeron P. Local anesthesia in carotid angioplasty. J Endovasc Surg. 1996;3:31–34. 7. Bergeron P, Becquemin JP, Jausseran JM, et al. Percutaneous stenting of the internal carotid artery: the European CAST I study. J Endovasc Surg. 1999;6:155–159. 8. Bergeron P. CAS: a review and meta-analysis. Presented at: The Veith Symposium; November 14–18, 2012; New York City, NY, USA. 9. Pinter L, Ribo M, Loh C, et al. Safety and feasibility of a novel transcervical access neuroprotection system for carotid artery stenting in the PROOF Study. J Vasc Surg. 2011;54: 1317–1323. 10. Palombo G, Stella N, Faraglia V, et al. Cervical access for filter-protected carotid artery stenting: a useful tool to reduce cerebral embolisation. Eur J Vasc Endovasc Surg. 2010;39:252–257. 11. Mantese VA, Timaran CH, Chiu D, et al. CREST Investi gators. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke. 2010;41(10 suppl): S31–S34.
Journal of Endovascular Therapy 22(1) 12. Ederle J, Dobson J, Featherstone RL, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375:985–997. 13. Liapis CD, Bell PR, Mikhailidis D, et al. ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg. 2009;37(4suppl):1-19. 14. Mathieu X, Piret V, Bergeron P, et al. Choice of access for percutaneous carotid angioplasty and stenting: a comparative study of cervical and femoral access. J Cardiovasc Surg (Torino). 2009;50:677–681. 15. Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol. 2008;7:893–902. 16. Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355:1660–1671. 17. Kastrup A, Gröschel K, Schnaudigel S, et al. Target lesion ulceration and arch calcification are associated with increased incidence of carotid stenting-associated ischemic lesions in octogenarians. J Vasc Surg. 2008;47:88–95. 18. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/ AHA/AANN/AANS/ACR/ ASNR/CNS/SAIP/SCAI/SIR/SNIS/ SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011;124: 489–532. Erratum: Circulation. 2011;124:e145. 19. Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363:11–23. 20. Faggioli GL, Ferri M, Freyrie A, et al. Aortic arch anomalies are associated with increased risk of neurological events in carotid stent procedures. Eur J Vasc Endovasc Surg. 2007;33:436-441. 21. Bersin RM, Stabile E, Ansel GM, et al. A meta-analysis of proximal occlusion device outcomes in carotid artery stenting. Catheter Cardiovasc Interv. 2012;80:1072–1078. 22. Gough MJ, Bodenham A, Horrocks M, et al. GALA: an international multicentre randomised trial comparing general anaesthesia versus local anaesthesia for carotid surgery. Trials. 2008;9:28. 23. Bergeron P, Benichou H, Rudondy P, et al. Stroke prevention during carotid surgery in high risk patients (value of transcranial Doppler and local anesthesia). J Cardiovasc Surg (Torino). 1991;32:713–719.
research-article2014
JETXXX10.1177/1526602814564362Journal of Endovascular TherapyBergeron
Technical Note
Direct Percutaneous Carotid Access for Carotid Angioplasty and Stenting
Journal of Endovascular Therapy 2015, Vol. 22(1) 135–138 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602814564362 www.jevt.org
Patrice Bergeron, MD1
Abstract Purpose: To describe a direct percutaneous carotid access technique for carotid artery stenting (CAS) that circumvents the potential for embolization that can occur during catheter manipulation in the aortic arch during femoral access. Technique: After inducing anesthesia, an ultrasound transducer is placed at the base of the neck above the clavicle. A 21-G, 7-cm needle from a micropuncture introducer is used for single-wall puncture of the common carotid artery (CCA). A 0.018-inch guidewire is inserted into the needle for placement of a 4-F, 10-cm introducer. After placing a 0.035-inch angled guidewire in the external carotid artery, the 4-F introducer is exchanged for the closure device sheath (preclose technique). A regular 6-F introducer is then placed inside the closure device sheath, and a low dose (2000 units) of heparin is administered for the brief CAS procedure, which is performed under cerebral protection. After a successful procedure is confirmed, the protection device is retrieved, and the closure device is applied to seal the puncture. Conclusion: This approach has a low rate of neurological and access site complications. Percutaneous direct carotid access could extend the indications for CAS to include difficult anatomies, high-risk patients, and certain emergent situations that warrant easy and rapid access to the CCA. Keywords carotid stenosis, carotid angioplasty, carotid stent, vascular closure device, direct cervical carotid puncture, ultrasound guidance, common carotid artery, cerebral protection Transfemoral access has long been the route of choice for carotid artery stenting (CAS).1,2 However, in difficult aortic arch anatomies (eg, gothic and bovine arches, tortuous carotid arteries, and shaggy or aneurysmal aortas), the need for arch manipulations increases the risk of embolization to the cerebral hemispheres. Facing these challenges, interventionists have developed alternative routes over the years.2–5 Among these approaches, direct common carotid artery (CCA) access has advocates. Some opt for a small cutdown, while we continue to pursue percutaneous access using low-profile introducer sheaths and low doses of heparin, which has resulted in excellent outcomes without significant access complications.6,7 The expected benefits of percutaneous direct carotid access are saving time and contrast and avoiding embolization from the aortic arch. Recently, several reports8–10 have emphasized the safety of direct carotid access for CAS, with a reduced number of new brain lesions on diffusionweighted imaging compared with femoral access. Looking to the recent trials comparing carotid endarterectomy (CEA) and CAS,11,12 there was no difference in terms of stroke/ death risk, but CEA increased the risk of myocardial infarction while CAS increased the risk of transient ischemic
attack (TIA). Reducing the number of TIAs might make CAS equivalent or better than CEA. The direct carotid access is one method of reducing the TIA risk by circumventing catheter manipulations in the aortic arch. This note describes a safe approach for CAS under direct carotid access that eliminates the risk of embolization that can occur during device navigation in the arch from the femoral route.
Technique Carotid artery stenting via a direct carotid access is undertaken using a micropuncture introducer set (Cook, Bloomington, IN, USA) and ultrasound guidance to ensure single wall puncture of the CCA. An ultrasound-guided puncture is advisable for anticoagulated patients, obese patients 1
Hôpital Privé Résidence du Parc, Marseille, France
Corresponding Author: Patrice Bergeron, Department of Thoracic and Cardiovascular Surgery, Hôpital Privé Résidence du Parc, 10 rue Gaston Berger, Marseille 13010, France. Email: [email protected]
136
Journal of Endovascular Therapy 22(1)
Figure 1. (A) Puncture of the common carotid artery (CCA) under ultrasound guidance. (B) Longitudinal view of the CCA with a guidewire inserted. (C) Placement of a 4-F introducer for delivery of the 0.035-inch guidewire to the external carotid artery. (D) Exchange of the 4-F introducer for the closure device sheath during the preclose technique. (E) Placement of a regular 6-F introducer in the closure device sheath, (F) which is then sutured to the skin. (G) Final appearance of the puncture after closure device application.
with reduced carotid pulsatility, low bifurcations requiring a very proximal puncture, and a frozen neck. The patient’s neck is extended with a cushion under the shoulders, and the C-arm is placed in a profile view. After establishing local or general anesthesia, the ultrasound transducer is placed at the base of the neck above the clavicle (Figure 1A), and a 21-G, 7-cm needle from a micropuncture introducer set (Cook Inc) is directed to the CCA parallel or perpendicular to the probe. A transverse or longitudinal view of the CCA (Figure 1B) is displayed on the screen showing the single-wall puncture. After carotid puncture, dye is injected to determine that there is enough room from the tip of the sheath to the carotid bifurcation for deploying the stent across the bifurcation and out of the sheath. If the puncture needs to be repeated without ultrasound guidance, a roadmap can be obtained by injecting contrast through the needle after placing the C-arm in an anteroposterior view. A 0.018-inch, 40-cm long guidewire is inserted into the needle for placement of a 4-F, 10-cm introducer (Figure 1C). The first angiogram is taken in a profile view. A 0.035inch angled guidewire is placed in the external carotid artery under roadmapping. The 4-F introducer is exchanged for the closure device sheath (Figure D1) not too far into the CCA (~1 cm checked on the roadmap). A preclose technique is recommended to avoid guidewire manipulations after stenting. A regular 6-F introducer is placed in the closure device sheath (Figure 1E); its position is checked by contrast injection and then the closure device sheath is fixed to the skin using 2 stitches (Figure 1F). A low dose of heparin (2000 units) is administered as the procedure is short.
Carotid artery stenting is performed as described elsewhere.13 A 0.014-inch guidewire is placed across the stenosis and a cerebral protection device of the operator’s choice is deployed. Stent placement and dilation (pre/post at the operator’s discretion) are followed by completion angiography at the bifurcation and brain levels. The protection device is retrieved, protamine is administered to reverse the heparin, and the closure device is applied to seal the puncture (Figure 1G).
Discussion Our group has performed over 300 CAS procedures via direct cervical access. The initial CAS cohort treated from December 1992 was reported in 2009.14 Among the 461 CAS procedures performed out of >2000 carotid procedures (~100/year), 254 were from a direct carotid access (routine use of a protection device began in 1999). In this subgroup, 2 patients presented with a TIA, 1 patient developed a major stroke from hyperperfusion syndrome (residual deficit limited to the right arm), and 1 patient developed monocular blindness. The stroke rate was 0.8%. No nerve palsy was observed. One cervical hematoma without lifethreatening complication was observed and resolved spontaneously without surgery, but in several other cases, a diffuse hematoma developed under the skin and was spontaneously reabsorbed. These may have been due to additional puncture of the CCA or excessive anticoagulation. Since 2013, we have used ultrasound-guided puncture and a closing device in the 52 patients (37 men; mean age 70.6 years, range 38–102) undergoing direct CCA access.
137
Bergeron All patients were taking clopidogrel (75 mg/d) or received a 300-mg loading dose the day before the procedure. All direct carotid access procedures were performed percutaneously with no need for cutdown, and a closure device was used for all. No death, stroke, TIA, nerve palsy, or cardiac events occurred in this series of patients undergoing CAS via percutaneous direct carotid access.
Technical Considerations Patients are selected for direct cervical access according to risk factors and anatomy. 1. Advanced age is traditionally considered high risk for CAS based on trial data11,12,15,16 that suggested a threshold of 70 years beyond which CEA is safer. We argue that elderly patients benefit from a less invasive technique and associated shorter hospitalization. Moreover, based on our experience, we believe that the increased risk of embolization is related to crossing the aortic arch in this population with advanced aortic disease.17 We opt for cervical access CAS in patients >70 years old if the arch is diseased and tortuous or in cases of incomplete arch imaging. 2. Recurrent stenosis after endarterectomy or radical neck surgery and postradiation stenosis are recognized indications for CAS.18,19 In some of these patients, we have performed cervical access, as the CCA is usually right under the skin, fixed by the scar tissue, and easily compressed. 3. Arch abnormality or disease that requires a complex procedure with several arch manipulations should be approached via a cervical access. The risk of contralateral or posterior brain embolization resulting from arch manipulations20 is eliminated with direct carotid access. Experienced and skilled operators will argue that the use of certain tools makes femoral access easy. However, we all recognize the increased time and risk associated with navigating arch anomalies (limiting the time to access the CCA to 15 or 20 minutes is recommended). In situations where a rapid procedure is advised, the direct carotid access is beneficial. 4. Technical failures in direct carotid stenting are not related to tortuosities but to difficulty crossing tight and calcified stenosis. As such, arteries with severe calcification exceeding 50% of the lumen circumference are not suitable for CAS. Ultrasound guidance is the best option when the equipment is available as it provides safe control of the puncture. There is a learning curve, and the first use of ultrasound
guidance can be done at the groin level. Ten cases at least are recommended to master the technique and start feeling comfortable with it. In our early experience, we closed the direct carotid access site using manual compression for at least 10 minutes. This approach was feasible and safe under the following conditions: the heparin dose was reduced from 5000 units for femoral access to 2000 units for cervical access procedures, and protamine was used to reverse the effects of heparin. The time saved by the direct carotid access approach allowed the lower heparin dose to cover the entire CAS procedure. We used a small introducer sheath, usually 6-F, and avoided making a double-wall puncture or multiple attempts at puncture. After a large experience using a closing device at the groin, we began successfully using it for the carotid application. We typically use Abbott’s StarClose device, which utilizes an adventitial nitinol clip providing 360° tissue apposition. We prefer this device over intraluminal closure devices that use anchors. By placing the device’s introducer at the beginning of the procedure, there is no need to place a guidewire across the stent. The closing device is advanced and the nitinol clip is delivered on the adventitia, securing the access. In the area of brain protection from embolization, it appears that blood flow reversal compares favorably to filter protection.21 The reverse flow technique can be used safely as a protective mechanism during local or general anesthesia provided the stump pressure is recorded, as we do during surgery. Combining direct carotid access with flow reversal might be the better option for CAS. A safe percutaneous approach with this protective device would considerably simplify the procedure. In our experience, this approach has never failed, and we have observed no complications related to stationary or reversed flow. We have performed percutaneous carotid access CAS under general anesthesia in most patients because it is comfortable for the patient and the operator and helps when using the roadmapping technique. The use of general anesthesia during direct carotid access CAS is not mandatory, and some interventionists perform direct carotid access with a cutdown and reverse flow protection under local anesthesia. There is no trial comparing local and general anesthesia for CAS as the GALA trial22 did for carotid surgery. GALA showed no difference in the proportion of patients with stroke, myocardial infarction, or death between general or local anesthesia in a large population. We opt for general anesthesia as we do for surgery, although we used local anesthesia in a previous surgical experience for high-risk patients before the advent of CAS.23
Conclusion Our experience suggests that percutaneous direct carotid access can be used safely and effectively for CAS, perhaps
138 even in patients with difficult anatomies, at high surgical risk, or in certain emergent situations that warrant easy and rapid access to the carotid artery. Acknowledgments The author wishes to thank Laurie LaRusso, MS, ELS, and Pierre Saint Girons for editorial assistance.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Diethrich EB, Ndiaye M, Reid DB. Stenting in the carotid artery: initial experience in 110 patients. J Endovasc Surg. 1996;3:42–62. 2. Diethrich EB, Marx P, Wrasper R, et al. Percutaneous techniques for endoluminal carotid interventions. J Endovasc Surg. 1996;3:182–202. 3. Al-Mubarak N, Vitek JJ, Iyer SS, et al. Carotid stenting with distal-balloon protection via the transbrachial approach. J Endovasc Ther. 2001;8:570–574. 4. Stella N, Palombo G, Filippi F, et al. Endovascular treatment of common carotid artery dissection via the superficial temporal artery. J Endovasc Ther. 2010;17:569–573. 5. Montorsi P, Galli S, Ravagnani PM, et al. Carotid artery stenting in patients with left ICA stenosis and bovine aortic arch: a single-center experience in 60 consecutive patients treated via the right radial or brachial approach. J Endovasc Ther. 2014;21:127–136. 6. Alessandri C, Bergeron P. Local anesthesia in carotid angioplasty. J Endovasc Surg. 1996;3:31–34. 7. Bergeron P, Becquemin JP, Jausseran JM, et al. Percutaneous stenting of the internal carotid artery: the European CAST I study. J Endovasc Surg. 1999;6:155–159. 8. Bergeron P. CAS: a review and meta-analysis. Presented at: The Veith Symposium; November 14–18, 2012; New York City, NY, USA. 9. Pinter L, Ribo M, Loh C, et al. Safety and feasibility of a novel transcervical access neuroprotection system for carotid artery stenting in the PROOF Study. J Vasc Surg. 2011;54: 1317–1323. 10. Palombo G, Stella N, Faraglia V, et al. Cervical access for filter-protected carotid artery stenting: a useful tool to reduce cerebral embolisation. Eur J Vasc Endovasc Surg. 2010;39:252–257. 11. Mantese VA, Timaran CH, Chiu D, et al. CREST Investi gators. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke. 2010;41(10 suppl): S31–S34.
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