Upper Extremity Approaches for Carotid Stenting
The utility of transradial and transbrachial access for difficult arch anatomy.
Carotid artery stenting (CAS) has been shown to be an effective treatment modality in patients with carotid artery occlusive disease.1-4 However, patients with complex aortic arch anatomy and octogenarians may be considered high risk, with increased stroke risk during CAS.5-8 Schneider et al identified severe aortoiliac disease, unfavorable aortic arch configuration (type II or III), bovine arch anatomy, and supra-aortic vessel take-off as conditions rendering CAS more difficult.9
CAS is typically performed via a transfemoral approach, which has a short learning curve and is advantageous in that the femoral artery can accommodate larger-diameter devices. Although infrequent, there are femoral artery access site complications.10,11 In addition, manipulation through the aortic arch can lead to increased embolic potential despite placement of an embolic protection device (EPD). An MRI-based study revealed that 40% of patients had evidence of cerebral embolization during transfemoral CAS.12 Sixty percent of the cerebral infarcts were outside the vascular territory of the treated lesion, suggesting that the emboli originated from the aortic arch. An approach that minimizes catheter manipulation in the aortic arch could possibly reduce the risks of CAS in patients with complex aortic arch anatomy.
Upper extremity approaches have previously been shown to be acceptable for coronary occlusive disease.13-16 Multiple large-volume studies have shown that complications from radial approaches have been incredibly low, while others have noted the benefits of both radial and brachial approaches specifically for CAS.13,14,17-26 One study showed that upper extremity approaches are also valuable for vertebral interventions.27 In particular, excellent results have been achieved with right brachial approaches in patients with left internal carotid artery (ICA) lesions and bovine arch anatomy,17 and with transradial access in patients undergoing CAS with bovine and type III aortic arch anatomy. This was demonstrated at one institution in which contralateral transradial approaches were utilized to treat patients requiring CAS.21
Our group employs CAS for patients who are considered to be at anatomic high risk for carotid endarterectomy (CEA). Most commonly, these patients have recurrent carotid lesions, a history of neck irradiation, high cervical lesions, or previous neck surgery. Typically, patients who are at physiologic high risk are treated with CEA under cervical block and sedation (our practice defines physiologic high risk as recent myocardial infarction, New York Heart Association class III/V angina, congestive heart failure, or oxygen-dependent chronic obstructive pulmonary disease). Our group utilizes upper extremity approaches for patients requiring CAS in the setting of a bovine and/or a type III aortic arch.
All patients are treated with clopidogrel for at least 5 days before the procedure. Brachial or radial approaches are used based on the operator’s experience, as well as a preprocedural Allen’s test. A SMAK micropuncture access set (Merit Medical Systems, Inc., South Jordan, UT) is used for brachial artery access, whereas a Glidesheath nitinol micropuncture set (Terumo Interventional Systems, Somerset, NJ) is utilized for radial artery access. Patients undergoing radial artery access have both verapamil (0.075–0.15 mg/kg) and nitroglycerin (100–200 μg for a 70-kg patient) given as boluses through the sheath as antispasmodics. Anticoagulation during the procedure is achieved upon access to the target vessel with unfractionated heparin with the goal to keep the activated clotting time > 350 seconds.
The target common carotid artery (CCA) is initially cannulated using standard techniques; usually a Cobra C2 (Terumo Interventional Systems), H1 (Cook Medical, Bloomington, IN), or a Berenstein (Boston Scientific Corporation, Natick, MA) catheter is employed. A 0.035- inch Glidewire (Terumo Interventional Systems) is then used to position the catheter into the CCA or external carotid artery, depending on the anatomy. The Glidewire is then removed and replaced with a 0.035-inch Rosen wire (Cook Medical). At that point, the 5-F sheath is exchanged out for a 6-F shuttle sheath (Cook Medical) and advanced over the wire once the target CCA or external carotid artery is engaged.
Carotid stenting is then performed using standard techniques. Either an Emboshield Nav6 (Abbott Vascular, Santa Clara, CA) or Angioguard RX (Cordis Corporation, Bridgewater, NJ) EPD is used. The stents typically utilized are Precise Pro RX (Cordis Corporation), RX Acculink (Abbott Vascular), or Xact (Abbott Vascular). After stenting, a 4- or 4.5-mm balloon is usually used for postdilatation. Once the procedure is completed, the heparin is actively reversed with protamine sulfate. Manual pressure is applied for brachial access, and a TR Band assisted compression device (Terumo Interventional Systems) is used for radial access.
CAS has been shown to be noninferior to CEA in regard to both efficacy and patient safety.2,6,8 We have a conservative approach when using CAS, choosing only to proceed with this treatment modality in patients who are deemed to be at anatomical high risk (patients having recurrent carotid lesions, a history of neck irradiation, high cervical lesions, or prior neck surgery). We perform CEA under cervical block and sedation in patients who are at physiological high risk. We use two imaging modalities in patients being considered for CAS: duplex ultrasonography and CTA are used preoperatively for both confirmation and case-planning purposes. Previous studies have shown the utility of preoperative CTA for CAS as well.7,19,22
Transfemoral approaches have been shown to be very efficacious and are the preferred method if feasible.2,6,8 However, transfemoral CAS may be difficult in patients with bovine and type III aortic arches.9 Studies have shown that manipulation of the aortic arch may lead to increased risk of stroke in both cerebral hemispheres.12
In our experience, CAS from upper extremity approaches can be performed safely and is effective in treating both left- and right-sided carotid lesions in those patients with type III or bovine arch anatomy. These approaches are patient selective and considered only after a careful review of all imaging studies to determine suitability. We were fortunate that our patient with a left ICA lesion, an ostial CCA lesion, and a type III arch had a previous left carotid subclavian bypass graft, enabling left brachial access to the left ostial CCA. Alternative approaches for endovascular treatment in patients with a left ICA stenosis and a type III arch include direct cervical puncture or left CCA cutdown.
Our experience over the past 7 years has shown that utilizing upper extremity approaches for CAS is effective and safe. During this period, we have had no access site complications in our 17 CAS patients. We have found brachial and radial approaches to be helpful, although our preference is for radial access in patients whose anatomy is suitable. In our experience with both diagnostic and therapeutic angiograms, radial approaches have less complications than brachial approaches. In particular, we have seen less access vessel thrombosis and less hematoma formation when accessing the radial artery compared to the brachial artery. Dual blood supply to the hand and a complete palmar arch is always confirmed prior to radial access. A transradial approach with postprocedure placement of a TR Band for hemostasis allows for quicker ambulation, and complications with the site are minimal. The upper extremity approach minimizes arch manipulation and has the advantage of decreased access site complications.
Others have found it beneficial to approach CAS from a contralateral radial access.21 We reserve the left radial access to treat left-sided lesions in patients with previous debranching procedures (eg, left common-to-subclavian bypasses, as this allows access to the ipsilateral ICA). We believe that by not crossing all three great vessels and having the least amount of arch manipulation possible, there should be decreased embolic events. In particular, we have found the right upper extremity approach to be beneficial in patients with right ICA or right CCA ostial lesions and a type III arch. We also employ a right upper extremity approach for left CCA and ICA lesions in the setting of a bovine arch. In the setting of a bovine arch, left-sided lesions should be preferentially treated from the right upper extremity, as this limits arch manipulation and the inherent embolic risks.
Patrick M.S. Neville, MD, is a fifth-year vascular integrated resident with the Department of Surgery at Good Samaritan Hospital in Cincinnati, Ohio. He has disclosed that he has no financial interests related to this article. Dr. Neville may be reached at firstname.lastname@example.org
Brian A. Kuhn, MD, is a vascular attending with the Department of Surgery at Good Samaritan Hospital in Cincinnati, Ohio. He has disclosed that he has no financial interests related to this article. Dr. Kuhn may be reached at email@example.com.
Matthew H. Recht, MD, is a vascular attending with the Department of Surgery and the Assistant Program Director of the Vascular Fellowship and Integrated Residency at Good Samaritan Hospital in Cincinnati, Ohio. He has disclosed that he has no financial interests related to this article. Dr. Recht may be reached at firstname.lastname@example.org.
Patrick E. Muck, MD, is Chief of Vascular Surgery and Program Director of the Vascular Fellowship and Integrated Residency at Good Samaritan Hospital in Cincinnati, Ohio. He has disclosed that he has no financial interests related to this article. Dr. Muck may be reached at email@example.com.
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- Silver FL, Mackey A, Clark WM, et al; Crest Investigators. Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke. 2011;42:675-680.
- Gray WA, Yadev JS, Verta P, et al; CAPTURE Trial Collaborators. The CAPTURE registry: predictors of outcomes in carotid artery stenting with embolic protection for high surgical risk patients in the early post-approval setting. Catheter Cardiovasc Interv. 2007;70:1025-1033.
- Gurm HS, Yadev JS, Fayad P, et al; SAPPHIRE Investigators. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008;358:1572-1579.
- Yates D. Stroke: early trial results favor surgery over stenting for symptomatic carotid artery stenosis. Nat Rev Neurol. 2010;6:237.
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- Bangalore S, Kumar S, Wetterslev J, et al. Carotid artery stenting vs carotid endarterectomy: meta-analysis and diversity adjusted trial sequential analysis of randomized trials. Arch Neurol. 2011;68:172-184.
- Schneider PA, Kasirajan K. Difficult anatomy: what characteristics are critical to good outcomes of either CEA or CAS? Semin Vasc Surg. 2007;20:216-225.
- Irani F, Kumar S, Colver WR Jr. Common femoral artery access techniques: a review. J Cardiovasc Med (Hagerstown). 2009;10:517-522.
- Sherev DA, Shaw RE, Brent BN. Angiographic predictors of femoral access site complications: implication for planned percutaneous intervention. Catheter Cardiovasc Interv. 2005;65:196-202.
- Hammer FD, Lacroix V, Duprez T, et al. Cerebral microembolization after protected carotid artery stenting in surgical high-risk patients: results of a 2 year prospective study. J Vasc Surg. 2005;42:847-853; discussion 853.
- Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary interventions: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008;1:379-386.
- Achenbach S, Ropers D, Kallert L, et al. Transradial versus transfemoral approach for coronary angiography and intervention in patients above 75 years of age. Catheter Cardiovasc Interv. 2008;72:629-635.
- Bertrand OF, De Larochelliere R, Rodés-Cabau J, et al. A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation. Circulation. 2006;114:2636-2643.
- Rao SV, Cohen MG, Kandzari DE, et al. The transradial approach to percutaneous coronary intervention historical perspective, current concepts, and future directions. J Am Coll Cardiol. 2010;55:2187-2195.
- Ventoruzzo G, Biondi-Zoccai G, Maioli F, et al. A tailored approach to overcoming challenges of a bovine aortic arch during left internal carotid artery stenting. J Endovasc Ther. 2012;19:329-338.
- Mendiz OA, Sampaolesi AH, Londero HF, et al. Initial experience with transradial access for carotid artery stenting. Vasc and Endovasc Surg. 2011;45:499-503.
- Montorsi P, Galli S, Ravagnani PM, Bartorelli AL. Commentary: matching the anatomy with the technique and vascular approach in carotid artery stenting. the role of systematic multidetector CT angiography. J Endovasc Ther. 2012;19:339-342.
- Etxegoien N, Rhyne D, Kedev S, et al. The transradial approach for carotid artery stenting. Cath Cardiovasc Interv. 2012;80:1081-1087.
- Patel T, Shah S, Ranjan A, et al. Contralateral transradial approach for carotid artery stenting: a feasibility study. Catheter Cardiovasc Interv. 2010;75:268-275.
- Dahm JB, van Buuren F, Hansen C, et al. The concept of an anatomy related individual arterial access: lowering technical and clinical complications with transradial access in bovine- and type-III aortic arch carotid artery stenting. Vasa. 2011;40:468-473.
- Fang HY, Chung SY, Sun CK, et al. Transracial and transbrachial arterial approach for simultaneous carotid and angiographic examination and stenting using catheter looping and retrograde engagement technique. Ann Vasc Surg. 2010;24:670-679.
- Gan HW, Bhasin A, Wu CJ. Transracial carotid stenting in a patient with bovine arch anatomy. Catheter Cardiovasc Interv. 2010;75:540-543.
- Bakoyiannis C, Ecnomopoulos KP, Georgopoulos S, et al. Transradial access for carotid artery stenting: a single-center experience. Int Angiol. 2010;29:41-46.
- Wu CJ, Cheng CI, Hung WC, et al. Feasibility and safety of transbrachial approach for patients with severe carotid artery stenosis undergoing stenting. Cath Cardiovasc Interv. 2006; 67:967-971.
- Yip HK, Youssef AA, Chang WN, et al. Feasibility and safety of transradial arterial approach for simultaneous right and left vertebral artery angiographic studies and stenting. Cardiovasc Intervent Radiol. 2007;30:840-846.