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

Abstract

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.

Combined Endovascular Antegrade and Direct Retrograde Carotid Artery Stenting for Chronic and Long Segment Common Carotid Artery Occlusion: Technical Note and Review of Literature

“…Besides the pull-through technique, combined endovascular antegrade and direct retrograde access enables strong support for lesion penetration, reduction of embolic complications by secure blockage of the distal blood flow, and reliable hemostasis by suturing the puncture site. 4 , 5 ) For certainty and safety, a hybrid strategy for the CCAO is recommended. Although this technique is a promising therapeutic option, ischemic complications due to vascular blockage and emboli must be considered.…”

“…Limited reports exist on antegrade and retrograde endovascular treatments for CCAO. [4][5][6] In reports of anterograde CAS for CCAO, the guidewire successfully passed through the occluded lesion via the catheter placed at the origin of the CCA. 7,8) Based on previous cases, endovascular treatment for CCAO is also suitable for Rile's classification type 1a, probably because normal vessels should be connected to other normal vessels.…”

Combined endovascular antegrade- and direct retrograde carotid artery stenting for chronic and long segment common carotid artery occlusion: technical note and review of literature

“…Endovascular treatment for CCAO 1) Limited reports exist on antegrade and retrograde endovascular treatments for CCAO 4,5,7 . In reports of anterograde CAS for CCAO, the guide wire successfully passed through the occluded lesion via the catheter placed at the origin of the CCA 6-8 .…”

“…The advantage of this technique is its versatility, regardless of the patent length of the origin of the CCA or tortuosity of the access route. In addition to the pull-through technique, combined endovascular antegrade and direct retrograde access enables strong support for lesion penetration, reduction of embolic complications by secure blockage of the distal blood ow, and reliable hemostasis by suturing the puncture site 4,5 . For certainty and safety, a hybrid strategy for the CCAO is recommended.…”