Objective: Proximal balloon protection (PBP) in carotid artery stenting via the transbrachial carotid artery stenting (TB-CAS) approach has not been feasible because a large-sized sheath introducer is required. We report a novel technique of TB-CAS using sheathless balloon guiding catheter navigation. Case presentation: A 76-year-old male presented with a symptomatic left internal carotid artery stenosis. Transfemoral approach was difficult because of severe arteriosclerosis obliterans. A 9Fr Optimo 90 cm was inserted into the right brachial artery over a 6Fr long dilator 108 cm by the coaxial method without sheath introducer, and it was advanced into the right subclavian artery. A long dilator was exchanged with an inner catheter and a 9Fr Optimo was navigated into the common carotid artery by using the telescoping technique. Further procedures were successfully performed by PBP using a 9Fr Optimo. The patient's postoperative course was uneventful, and follow-up head MRI did not reveal any distal embolization. Conclusion: This technique is useful in high-risk patients of distal thromboembolic complication in CAS with difficult femoral access, because it enables PBP by TB-CAS.
Summary:Background: The indication of extracranial-intracranial (EC-IC) bypass surgery is likely to be limited, because the prognosis for ischemic stroke improves with better outcomes with medical therapy. Therefore, to achieve the maximum benefit in selected cases, an individualized surgical plan tailored to anatomical differences and the purpose of the surgery is necessary. We describe our practical application of 3-D multifusion imaging for "tailored" bypass surgery.
Methods:We selected the ideal recipient artery and simulated the craniotomy preoperatively using 3-D multifusion imaging on a general purpose workstation in 13 cases of EC-IC bypass treated in Kokura Memorial Hospital between October 2011 and October 2012. We identified discrepancies between imaging and the actual intra-operative view, and modified the image editing and operative procedure.Results: In all 13 cases, bypass flow was maintained. There were positional deviations between the simulated craniotomy and the intra-operative view in two cases initially. In another two cases, we could not select the recipient artery because of insufficient visualization of the brain surface.Both problems were correctable.
Conclusion:We accurately identified the recipient artery that we had selected pre-operatively.This technique can be a stepping stone to "tailored bypass" and could be applied to various cerebrovascular surgeries.
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