Contralateral transradial approach for carotid artery stenting: A feasibility study

Background : Carotid artery stenting (CAS) has become an accepted modality of treatment for revascularization of the internal carotid artery (ICA). CAS from femoral approach has got wide acceptance, however, it can be problematic due to access site complication as well as technical difficulties related to peripheral vascular disease and/or anatomical variations of the aortic arch. Small feasibility studies of CAS through ipsilateral transradial approach have been described in the literature. The purpose of the present study is to evaluate the feasibility of contralateral transradial approach as an alternative approach for CAS. Methods : Twenty patients (mean age: 65 ± 5, 17 male) underwent CAS using contralateral transradial approach. All had a CA stenosis greater than 80%. The target common carotid artery (CCA) was initially cannulated via the contralateral radial artery using a 5F Simmons 1 diagnostic catheter or a 5F TIG diagnostic catheter, which was then advanced to the external CA (ECA) over an exchange length of 0.032″ Terumo Glidewire or a 0.025″ Glidewire. Once the catheter was parked in the optimal position in ECA, the wire was removed and was replaced by 0.035″ Amplatz Super stiff Guide wire. Following that, the Simmons 1 or the TIG catheter was removed and 6F Pinnacle Sheath was exchanged and positioned in the distal CCA. CAS was performed using standard techniques with weight‐based heparin for anticoagulation. Results : CAS was successful in 16/20 (80%) patients, including 12/12 (100%) right CA, 4/8 (50%) left CA. Mean interventional time was 40 ± 5 min. The sheath was removed immediately after the procedure. There were no radial access site complications. One patient sustained a transient ischemic attack and recovered completely with complete resolution of symptoms within 1 hr. Median Hospital stay was 3 ± 0.5 days. Angulation of left CCA with the aortic arch was the technical cause of failure in the four unsuccessful cases. Conclusion : CAS using the contralateral transradial approach appears to be safe and technically feasible. The technique may be particularly useful in patients with right ICA lesions because of the favorable right CCA angle with the aortic arch. © 2009 Wiley‐Liss, Inc.     

Complex carotid stenting using a coronary technique

PURPOSE: To report the utility of a coronary technique to facilitate carotid stenting in patients with difficult arch anatomies. TECHNIQUE: When confronted with challenging arch anatomy that prevents engaging the common carotid artery (CCA) with the guiding sheath using standard techniques, an 8-F left Amplatz guiding catheter (AL1) is placed at the origin of the innominate artery. A 0.014-inch coronary guidewire is advanced into the external carotid artery (ECA), and a small monorail coronary balloon is inflated in a small branch of the ECA. The balloon/guidewire combination facilitates maneuvering a 0.035-inch Amplatz super-stiff guidewire through the ECA and then advancing the guiding catheter into the CCA. CONCLUSION: This anchoring technique can be a helpful method for cannulating the CCA in patients with a complex arch when the ECA is patent.     

Differential effects of carotid artery stenting versus carotid endarterectomy on external carotid artery patency.

PURPOSE: To determine the effect of stent coverage of the external carotid artery (ECA) after carotid artery stenting (CAS) compared to eversion endarterectomy of the ECA after carotid endarterectomy (CEA). METHODS: The records of 101 CAS and 165 CEA procedures performed over 2 years were reviewed. Duplex velocities and history and physical examinations were taken prior to the procedure, at 1 month, and at 6-month intervals subsequently. CAS was performed by extending the stent across the internal carotid artery (ICA) lesion into the common carotid artery (CCA) thereby covering the ECA. CEA was performed with eversion endarterectomy of the ECA. RESULTS: The mean peak systolic velocities (PSV) in the ICA pre-CAS and pre-CEA were 361 and 352 cm/s, respectively. In terms of CAS, there was a significant increase in ECA velocities versus baseline at 12 (p = 0.009), 18 (p = 0.00001), and 24 (p = 0.005) months. In the CEA group, there was a significant decrease in ECA velocities versus baseline at 1 (p = 0.01) and 6 (p = 0.004) months. There were 2 occluded ECAs in follow-up in the CAS group and none in the CEA group. No significant differences were noted when comparing preprocedural ICA or ECA velocities. However, at the 1-, 6-, and 12-month intervals, the ECA velocities in the CAS group were significantly higher than in the CEA group (p = 0.03, p = 0.001, and p = 0.0004, respectively). There were no neurological symptoms in any patients during the study period. CONCLUSION: Although progressive stenosis of the ECA is noted during CAS, the ECA usually does not occlude. Furthermore, there are no associated neurological symptoms. Thus, apprehension for progressive ECA occlusion should not be a contraindication to CAS. In addition, concern for ECA coverage should not deter stent extension from the ICA to the CCA during CAS.     

Fate of the external carotid artery following carotid interventions

OBJECTIVE:

The external carotid artery (ECA) is an important collateral pathway for cerebral blood flow. Carotid artery stenting (CAS) typically crosses the ECA, while carotid endarterectomy (CEA) includes deliberate ECA plaque removal. The purpose of the present study was to compare the long-term patency of the ECA following CAS and CEA as determined by carotid duplex ultrasound.

METHODS:

Duplex ultrasounds and hospital records were reviewed for consecutive patients undergoing CAS between February 2002 and April 2008, and were compared with those undergoing CEA in the same time period. Preoperative and postoperative ECA peak systolic velocities were normalized to the common carotid artery (CCA) as ECA/CCA ratios. A significant (80% or greater) ECA stenosis was defined as an ECA/CCA ratio of 4.0. A change of ratio by more than 1 was defined as significant. Data were analyzed using Student’s t test and χ² analysis.

RESULTS:

A total of 86 CAS procedures in 83 patients were performed (81 men, mean age 69.9 years). Among them, 38.4% of patients had previous CEA, 9.6% of whom had contralateral internal carotid artery occlusion. Sixty-seven CAS and 65 CEA patients with complete duplex data in the same time period were included in the analyses. There was no difference in the incidence of severe ECA stenosis on preoperative ultrasound evaluations. During a mean follow-up of 34 months (range four to 78 months), three postprocedure ECA occlusions were found in the CAS group. The likelihood of severe stenosis or occlusion following CAS was 28.3%, compared with 11% following CEA (P<0.025). However, 62% of CEA patients and 57% of CAS patients had no significant change in ECA status. Reduction in the patient’s degree of ECA stenosis was observed in 9.4% of CAS versus 26.6% of CEA patients. Overall, immediate postoperative ratios of both groups were slightly improved, but there was a trend of more disease progression in the CAS group during follow-up.

CONCLUSION:

CAS is associated with a higher incidence of post-procedure ECA stenosis. Despite the absence of neurological symptoms, a trend toward late disease progression of ECA following CAS warrants long-term evaluation.     

Transcervical approach with protective flow reversal for carotid angioplasty and stenting.

PURPOSE: To report our initial experience using a transcervical approach for carotid angioplasty/stenting (CAS) that employs internal carotid artery (ICA) flow reversal for neuroprotection. METHODS: Seventeen patients (15 men; mean age 65 years, range 49-77) with significant carotid stenosis (mean 88%, 8 symptomatic) were treated with protected transcervical CAS. Eleven patients were considered at high risk for carotid endarterectomy; 8 were also considered high risk for transfemoral access (unfavorable aortic arch anatomy or advanced aortoiliac occlusive disease). Anesthesia was based on patient and anesthesiologist preferences. The approach consisted of a 2-cm cutdown over the common carotid artery and placement of a 9-F sheath. ICA flow was reversed and shunted into the jugular vein during the carotid intervention. RESULTS: Access and carotid stenting were successful in all cases. Thirteen procedures were performed under general and 4 under local anesthesia. Mean flow reversal time was 34+/-4 minutes (25 minutes in the last 7 cases). The patients tolerated the procedure well and had no neurological events. Four (23%) patients had significant oozing from the operative site; 2 developed small neck hematomas that were treated conservatively. All patients were discharged on the first postoperative day. There were no deaths, changes in neurological status, or restenosis over a mean follow-up of 12 months (range 1-24). CONCLUSIONS: Our initial experience demonstrates that a transcervical approach is a viable alternative for CAS. The procedure can be performed safely, with good initial clinical outcomes. The approach allows carotid flow reversal and emboli protection without introducing neuroprotection devices. The method appears best suited for patients at high risk for endarterectomy and transfemoral access.     

A modified technique for carotid cannulation via the transfemoral approach, during angioplasty and stent placement

We report a modified technique for advancing a catheter or sheath into the right common carotid artery when the aortic arch anatomy is unfavorable.A standard 0.035-inch guidewire is passed into the right subclavian artery, and a diagnostic catheter is threaded over it, deep into the right axillary and brachial artery. This wire is exchanged for a stiffer wire (for example, a super-stiff Amplatz), and the catheter is removed. This stiff wire acts as an anchor and provides enough support for a sheath or a guide catheter to be easily advanced into the right brachiocephalic artery, up to its bifurcation into the subclavian and common carotid arteries. Another wire is then buddy-wired through the guide or sheath into the common carotid artery and is placed in a branch of the external carotid artery. The stiff wire is now slowly withdrawn from the subclavian artery, and as soon as its tip exits the subclavian ostium, the guide or sheath is advanced into the common carotid artery.This simple modification can improve the success rate of carotid cannulation via the femoral approach without increasing procedural risks.     

A percutaneous technique for preservation of arch branch patency during thoracic endovascular aortic repair (TEVAR): retrograde catheterization and stenting.

PURPOSE: To report a percutaneous endovascular technique to deal with stent-graft encroachment and coverage (partial or total) of the origin of the left common carotid artery (CCA) or the left subclavian artery during thoracic endovascular aortic repair. TECHNIQUE: Percutaneous retrograde puncture of the left CCA was accomplished with guidewire advancement into the ascending aorta and insertion of a 6-F sheath. Balloon angioplasty and deployment of a stent across the origin of the left CCA successfully recanalized the vessel and restored normal antegrade flow and pressure. It was reasoned that the stent would maintain vessel patency by focally displacing the endograft device, preventing partial or total coverage (and obstruction) of the arch branch origin. This technique has been used successfully in 8 patients, 6 involving the left CCA and 2 the left subclavian artery. Two of the patients were lost to follow-up after 6 and 12 months. The other 6 patients have been followed from 10 to 32 months; the stented vessels have remained patent in all. CONCLUSION: While the "interposition" of a bare metal stent between a thoracic endograft and the aortic wall is theoretically unappealing and potentially detrimental, as the direct interaction between the devices might undermine the integrity of one or both, we have not seen such problems in this limited clinical experience.     

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

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. © 2010 Wiley‐Liss, Inc.     

Filter-protected carotid stenting via a minimal cervical access with transitory aspirated reversed flow during initial passage of the target lesion.

PURPOSE: To evaluate the preliminary results of filter-protected carotid artery stenting (CAS) via a minimal cervical access, with temporary common carotid artery (CCA) occlusion and aspiration in selected high-risk candidates for carotid endarterectomy. METHODS: Since February 2002, 26 patients (17 men; mean age 73.7 years, range 54-98) at high surgical risk according to the SAPPHIRE eligibility criteria underwent 29 transcervical CAS procedures under filter protection. Under general anesthesia, a 6-F short introducer sheath was directly mounted in the CCA through a small (2-4 cm) laterocervical cutdown. The CCA was briefly clamped, and blood was aspirated while the filter device was positioned above the target lesion. With the filter in place and the clamp released, nitinol stents were deployed under filter protection. Hemostasis was achieved by direct suture. RESULTS: Twenty-eight (96%) interventions were technically successful; 1 complex lesion could not be crossed and was converted to surgery. Mean clamping time was 1.7 (range 1.0-3.5) minutes. Combined 30-day stroke/mortality was 0%. Ultrasound surveillance demonstrated a < 60% asymptomatic in-stent restenosis in 1 (4%) patient with radiation-induced arteritis after 28 months. During a mean follow-up of 11.6 months (range 3-38), 1 (4%) minor ipsilateral stroke was noted at 6 months in a patient whose antiplatelet therapy was transitorily interrupted. CONCLUSION: Our preliminary observations from this small early experience suggest that this variant CAS technique is feasible and probably diminishes the neuroembolic risk during initial navigation of the ICA target stenosis.     

Ultrasound velocity criteria for carotid in-stent restenosis.

OBJECTIVE: To examine duplex ultrasound (US) criteria for carotid in-stent restenosis (ISR). BACKGROUND: Carotid artery stent (CAS) placement is an alternative to surgery for the treatment of carotid stenosis in high surgical risk patients. US is the primary method used to follow carotid stent patency. This study investigates US velocity measurements in carotid ISR. METHODS: Two hundred sixty consecutive patients with CAS placement from June 2000 to June 2004 were followed with serial US. ISR was determined by using the standard US velocity criteria for nonstented carotid artery using peak systolic velocity (PSV), end-diastolic velocity (EDV), and internal carotid artery to common carotid velocity ratio (ICA/CCA ratio). Patients suspected of having carotid ISR > or =50% by US, underwent invasive angiography with stenosis graded by NASCET criteria. Results were compared to patients with nonstented carotid artery stenosis using Two-tailed Student's t-test. RESULTS: PSV and ICA/CCA ratio increased to a greater degree in ISR. In 50-69% stenotic arteries, the mean ICA/CCA ratio was 2.76 +/- 0.7 in the ISR group compared to 2.04 +/- 0.3 in the nonstented carotid group (P < 0.05). In > or =70% stenotic arteries, there were increases in PSV (520 +/- 93 vs. 362 +/- 60, P < 0.05) and ICA/CCA ratio (7.58 +/- 2 vs. 4.51 +/- 1.3, P < 0.05) in ISR versus nonstented carotid arteries, respectively. CONCLUSION: PSV and ICA/CCA ratio in ISR increased to a greater extent for angiographic stenosis > or =50%. PSV 240 cm/sec and ICA/CCA ratio 2.45 are optimal thresholds for > or =50% ISR, and PSV 450 cm/sec and ICA/CCA ratio 4.3 are optimal thresholds for > or =70% ISR.     

经桡动脉普通导引导管7F无鞘技术治疗冠状动脉复杂病变

目的 评价经桡动脉普通导引导管7F无鞘技术治疗冠状动脉复杂病变的安全性、可行性.方法 纳入2013年11月至2014年4月,经桡/尺动脉置入6F桡动脉鞘造影后,需要用7F导引导管行介入治疗的患者31例.在桡动脉鞘内置入长260 cm,直径0.036 in（1 in=2.54 cm）非亲水涂层导丝至升主动脉;撤出桡动脉鞘,将6 F 110 cm猪尾管插入7 F 100 cm导引导管内,猪尾管头端突出于导引导管外;将猪尾管和导引导管呈一体,穿入长260 cm,直径0.036 in导引导丝,通过皮肤切口逐次进入桡动脉,导引导管到位后撤出猪尾管.结果 31例导引导管均成功通过桡动脉,到达靶冠状动脉开口,完成介入治疗后撤出导引导管.术后观察24 h,所有患者桡动脉穿刺处无出血,穿刺侧上肢未发生血肿、感觉障碍.术后1个月随访,未发生桡动脉闭塞.结论 经桡动脉普通导引导管7F无鞘技术是治疗冠状动脉复杂病变可选用的相对安全、有效的途径.     

Treatment strategies for carotid stenosis in patients at increased risk for surgery

The purpose of carotid revascularization is stroke prevention. The merits of carotid revascularization as well as the type of revascularization are dependent on the “natural risk” and the “revascularization risk.” In general, the natural risk of stroke in any patient with carotid stenosis (CS) is dependent on the symptomatic status of the patient and CS severity. Contemporary choices for carotid revascularization include carotid endarterectomy (CEA) and carotid artery stenting (CAS). Anatomical (hostile neck situations, severe bilateral CS, CEA restenosis) and clinical (severe cardiopulmonary diseases, prior cranial nerve injury) factors may increase the risk of CEA. Likewise, anatomical (complex aortic arch and brachiocephalic arterial anatomy, presence of thrombus, and heavy calcification) and clinical (need for heart surgery within 30 days) factors may increase the risk of CAS. Other factors such as the presence of symptomatic CS (transient ischemic attack or stroke within 6 months), decreased cerebral reserve, chronic kidney disease, and age older than 75 years may increase the risk of CEA and CAS. In general, symptomatic patients with severe CS exceed revascularization risk. In contrast, asymptomatic patients who are high risk for CEA should be considered for CAS because the natural risk of stroke should undergo careful assessment of baseline cognitive function, aortic arch and carotid artery anatomy, and likelihood of survival for 3 years. Patients who have normal cognitive function, favorable anatomy, and high likelihood of survival more than 3 years should be considered for CAS, whereas patients with multiple unfavorable features may be treated with optimal medical therapy, without revascularization.     

Comparison of catecholamine hormone release in patients undergoing carotid artery stenting or carotid endarterectomy.

PURPOSE: To investigate the pattern of catecholamine response in patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS: Adrenaline, noradrenaline, and renin levels were measured at 5 time points in 12 patients undergoing 13 CEAs (1 bilateral) and 13 patients undergoing unilateral CAS. Arterial blood samples were taken at the following time points: (1) after induction in CEA patients or 5 minutes following first contrast injection in CAS patients, (2) 5 minutes following ICA clamp release in surgical patients or deflation of the balloon in the CAS cohort, (3) 60 minutes following ICA clamp release in surgical patients or deflation of the balloon in the CAS cohort, and (4) 24 hours following the procedure. Intraoperative blood pressure and heart rate were recorded using radial arterial monitoring. Changes in adrenaline, noradrenaline, and renin levels are expressed as ratios versus baseline. RESULTS: Patterns of adrenaline and noradrenaline release were significantly different in patients undergoing CAS and CEA, with much higher and more variable surges of adrenaline and noradrenaline occurring in CEA patients. Adrenaline and noradrenaline levels increased significantly over baseline following carotid artery clamping in patients undergoing CEA (noradrenaline ratio before clamping: 1.54+/-1.25, 24 hours after unclamping: 8.38+/-16.35 [p<0.001]; adrenaline ratio before clamping: 1.12+/-0.49, 60 minutes after unclamping: 17.59+/-19.14 [p<0.001]). Conversely, in patients undergoing CAS, catecholamine levels remained unchanged (noradrenaline ratio before dilation: 0.96+/-0.23, 24 hours after the procedure: 0.92+/-0.32 [p=NS]; adrenaline ratio before dilation: 0.83+/-0.33, 60 minutes after balloon deflation: 0.56+/-0.32 [p=NS]). CONCLUSIONS: CAS is associated with a significantly less marked catecholamine response than CEA, which may reflect down-regulation of the sympathetic nervous system in response to carotid sinus stimulation during carotid angioplasty.     

Intraoperative innominate and common carotid intervention combined with carotid endarterectomy: a "true" endovascular surgical approach.

PURPOSE: To report the technique of carotid endarterectomy (CEA) combined with retrograde balloon angioplasty and stenting of proximal "tandem" lesions in the supra-aortic trunk. TECHNIQUE: Intraoperative techniques in 34 patients with 23 left common carotid artery (CCA) and 11 innominate artery lesions included general anesthesia, low-dose dextran, prosthetic patching, selective shunting, 8-F sheath entry into the native CCA before the CEA, manual CCA sizing, and balloon-expandable stent placement after predilation. The technique has a high procedural success rate (97%) and appears durable. Over a mean 34-month follow-up, 2 >70% ostial CCA restenoses were found at 24 months. CONCLUSIONS: Intraoperative innominate or left CCA balloon angioplasty/stenting combined with carotid endarterectomy is safe, effective, and durable.     

Endovascular repair of ascending aortic pseudoaneurysm: technical considerations of a common carotid artery approach using the Zenith aortic cuff endograft.

PURPOSE: To present a technique for endovascular treatment using Zenith aortic cuff extenders delivered via a left common carotid artery (CCA) approach in a patient with a large symptomatic ascending aortic pseudoaneurysm. CASE REPORT: A 78-year-old man with recent stroke developed worsening exertional dyspnea and chest pain 4 years following coronary artery bypass grafting. Imaging demonstrated a bovine arch and an 8-x12-cm ascending aortic pseudoaneurysm that was compressing the pulmonary arteries. The treatment strategy was to deliver a Zenith aortic cuff to seal the ascending aortic pseudoaneurysm via a left CCA approach. With the patient under general anesthesia, the left CCA was exposed and a transverse arteriotomy was made to introduce the Zenith aortic cuff sheath; the distal CCA was clamped to prevent catheter-related embolization. With its nosecone removed, a 32-x36-mm Zenith aortic cuff was delivered to the ascending aorta via the left CCA and positioned under transient cardiac arrest initiated with intravenous adenosine. A total of 3 Zenith aortic cuffs were placed in the ascending aorta to successfully exclude the pseudoaneurysm. The patient tolerated the procedure well; follow-up imaging showed successful pseudoaneurysm exclusion without endoleak. CONCLUSION: Ascending aortic pseudoaneurysm is a formidable clinical challenge due in part to the significant operative stress in a conventional surgical repair, as well as limited endovascular treatment options. Because there are no approved endovascular devices for ascending aortic aneurysm repair, clinicians may have to rely on endograft components designed for abdominal aortic aneurysms to treat lesions in the ascending aorta.     

Brachial access technique for aortoiliac stenting revisited

We report a modified technique to perform iliac artery stenting through the brachial artery access. A 6F Brite tip sheath (Cordis, Jonhson &amp; Jonhson Medical, Miami Lakes, FL, USA) is inserted into either brachial artery and a standard 4F Judkins Right diagnostic catheter was inserted over a 260 cm 0.038“ Terumo Stiff wire (Terumo Corp, Tokyo, Japan) through the sheath. The catheter is navigated down to the aortic bifurcation, and after selecting the common iliac artery ostium, the wire is navigated through the lesion and advanced to the ipsilateral superficial femoral arteries. The catheter should be then moved forward over the wires beyond the lesion and the Terumo guidewire is replaced by two 0.038“ 260 cm Supracor wires (Boston Scientific Corporation, San Jose, CA, USA). In order to facilitate advancement of the stent without risk of dislodgement as well as to check the position with low contrast dose injection, a 6 F (or 7F if large stent is selected) 90cm Shuttle Flexor introducer long sheath (Cook Group, Bloomington, IN, USA) should be advanced over the Supracor wire until it reaches the common iliac artery ostium. A road-map technique can be used to check the ostium position in order to properly deploy the selected stent. This technique promises to be safe and effective offering more support than guiding catheter technique; moreover it reduces the stress on the arterial vessel at the subclavian site and enables a stiff balloon or stent catheter to be advanced even through a very elongated and calcified aorta without the risk of stent dislodgement.     

Transulnar carotid artery stent placement

Carotid artery stenting (CAS) has increased in popularity as an alternative to carotid artery endarterectomy for the treatment of significant carotid artery stenosis. The access site is predominantly the femoral artery, with radial or brachial access used less often. Here, we describe a case of CAS after failure of brachial access. Transulnar CAS was performed successfully without complications. Transulnar access represents an additional option in a patient undergoing CAS when conventional femoral, brachial, and radial arteries are not applicable. © 2012 Wiley Periodicals, Inc.     

Carotid artery approach for balloon dilation of aortic valve stenosis in the neonate: a preliminary report

Balloon valvuloplasty in neonates with severe aortic valve stenosis is limited by difficulties in catheter manipulation around the arch and across the valve and by the risk of femoral artery complications. A right common carotid artery cutdown was utilized for balloon aortic valvuloplasty in five neonates 1 to 20 days of age, weighing 3.1 to 3.9 kg. Standard balloon valvuloplasty was performed through a 6F sheath inserted in the right carotid artery. The arteriotomy was repaired at the end of the procedure. Mean left ventricular systolic pressure was reduced from 142 to 97 mm Hg, with a decrease in mean peak systolic pressure gradient from 76 to 33 mm Hg. Only one patient developed mild aortic regurgitation. One patient with a hypoplastic left ventricle died, and one patient required open valvotomy. All four survivors have a normal carotid pulse and no neurologic sequelae. Two of these patients required repeat balloon dilation to treat residual aortic valve stenosis at 8 and 10 months of age, respectively. Balloon valvuloplasty using a carotid artery approach is feasible and was safe in five neonates with severe aortic valve stenosis.     

Microembolization during carotid stenting with the distal-balloon antiemboli system.

BACKGROUND: The distal-balloon protection system is being evaluated for its efficacy in preventing embolic neurological events during carotid stenting (CAS). We sought to determine the effect of this system on the frequency of the Doppler-detected microembolic signals (MES) during CAS. METHODS: Using transcranial Doppler, we compared the frequency of MES during CAS in 2 groups; 39 patients without distal protection and 37 with the distal-balloon protection system (GuardWire, Percusurge, Sunnyville, CA). There was no significant difference in the clinical or angiographic characteristics between the 2 groups. Three phases with increased MES counts were identified during the unprotected CAS; stent deployment, predilation, and postdilation (mean+/-SD: 75+/-57, 32+/-36, and 27+/-25, respectively). RESULTS: The distal-balloon protection significantly reduced the frequency of MES during CAS (MES-counts: 164+/-108 in the control vs 68+/-83 in the protection group, p=0.002) particularly during these 3 phases. MES in the protection group were detected predominantly during sheath placement, guidewire manipulation and during the distal-balloon deflation. CONCLUSIONS: Three phases with increased MES counts were identified during the unprotected CAS, e.g. stent deployment, predilation and postdilation. The distal-balloon protection system significantly reduced the frequency of MES during CAS, particularly during these 3 phases.     

经桡动脉途径行颈动脉支架置入术

目的 探讨经桡动脉途径行颈动脉支架治疗的可行性及安全性.方法 2011年2月至2011年12月邵逸夫医院心内科行颈动脉造影明确颈动脉狭窄≥70％患者12例通过桡动脉途径行颈动脉支架置入术.探讨手术成功率和并发症情况.结果 经桡动脉途径行颈动脉支架12例,左侧颈内动脉6例,右侧颈内动脉6例,均成功置入.平均手术时间(45 ± 11) min.1例术中出现TIA,2小时后恢复,2例术中出现血压、心率下降,予对症处理后,立即恢复,无桡动脉闭塞及前臂血肿等并发症.结论 经桡动脉途径行颈动脉支架治疗初步证明是安全可行的.