Feasibility of the 3D RCA catheter to engage the brachiocephalic vessels during carotid angiography and stenting

Abstract

Background: Engagement of the brachiocephalic vessels during carotid angiography is performed using a JR-4, Vitek, or other catheters with variable success. These catheters require additional training for safe manipulation. In this study, we evaluated the feasibility of using the 3D RCA catheter which requires less manipulation in the aorta, and less training, to engage the brachiocephalic vessels. Methods: We prospectively studied consecutive high-risk patients undergoing carotid angiography and stenting from August 2005 to March 2009 at our institution. A baseline aortogram was performed to define the arch type in all patients. Engagement of the brachiocephalic vessels was initially attempted using the 3D RCA catheter using the following approach: The 3D RCA catheter is positioned in the ascending aorta beyond the brachiocephalic vessels take off. The natural curve of the catheter usually makes it point cephalad spontaneously in most patients and as it is gently withdrawn it engages the aortic arch vessels without much manipulation. Clinical follow-up with a neurological exam was performed at one month and six months. Results: A total of 52 patients were enrolled in this study. Baseline demographics and aortic arch types encountered are listed in Table I. The 3D RCA catheter readily engaged the brachiocephalic vessels in 50/52 patients (96.0 %) in our cohort of patients undergoing carotid angiography. Of the 52 patients, 43 subsequently underwent carotid stenting and shuttle sheath placement was facilitated by initial engagement of the relevant common carotid artery with the 3D RCA catheter. There was one transient neurologic complication that resolved by 5 days in a patient that underwent carotid stenting. Conclusions: The 3D RCA catheter can be used with a high success rate to engage the brachiocephalic vessels in all 3 arch types, including a bovine arch during carotid angiography and facilitates shuttle sheath placement for carotid stenting. It requires less manipulation and therefore may be a more operator friendly approach.V C 2010 Wiley-Liss, Inc.

Takeoff orientation of the major aortic arch branches irrespective of arch type: Ramifications for brachiocephalic interventions including carotid stenting

“…12 These age-related changes in AA anatomy generally coexist with Source: Used with authors' permission. 1 increased calcification, tortuosity, and elongation of the transverse, ascending and descending aorta especially in patients above the age of 80 years. 13 Both Lam and Katstrup suggested in retrospective subgroup analyses in the carotid revascularization endarterectomy versus stenting trial (CREST) that altered arch anatomy was associated with significantly higher periprocedural cerebrovascular events especially in octogenarians.…”

“…The ease and predictability of cannulation of the major aortic arch branches (MAAB), irrespective of arch type, with an upwardly pointing 3DR catheter without manipulation as it is gradually withdrawn from right to left led us to hypothesize that a “cresting” of the MAAB must occur along a curvilinear line traversing the superior most aspect of the aortic arch (AA) 1 ( Figure 1 ). Following simple laws of physics dictated by centrifugal forces generated by bending of catheters as they are gently withdrawn in the AA the tip of torque free upwardly pointing 3D RCA catheter automatically seeks this superior most curvilinear line and effortlessly falls into the MAAB take off sequentially.…”

Pivotal Role of Major Aortic Arch Branches in Subtending the Mammalian Heart

“…During cardiac catheterization and coronary angiography, the ease and predictability with which an upwardly pointing coronary catheter engaged the MAAB as it was being withdrawn led us to suspect and later prove that the MAAB take off is crested along the superior most aspect of the AA [1].…”