Carotid neurointervention

[Hamhock]

How common is carotid access for MCA intervention or ICA stenting?

How often in your hospital?

Do you know of other centers where docs insert catheters through the carotid artery for neurointervention?

HH

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[TUGM]

How common is carotid access for MCA intervention or ICA stenting?

How often in your hospital?

Do you know of other centers where docs insert catheters through the carotid artery for neurointervention?

HH

Please note: I am a medical student... I've done a few months of NIR/IR rotations and shadowing. I dont think I have yet seen a procedure where access the the vascular system was gained through the carotids.

Most of the time, an infra-inguinal femoral approach was used w/ a micro-puncture kit, and wires were snaked up through the carotids. I know that a radial access can and has been used before too, but it is much less common.

I think the problem with carotid access is that it's a fairly large caliber vessel, and the risk of excessive hemorrhage is higher than with femoral access... I can imagine micro puncture spraying blood everywhere.

 

[typhoonegator]

How common is carotid access for MCA intervention or ICA stenting?

How often in your hospital?

Do you know of other centers where docs insert catheters through the carotid artery for neurointervention?

HH

Never, to my knowledge. Definitely never for MCA intervention, because I know all those guys. Not sure if the vascular surgeons have ever done a CCA puncture for an ICA stent, but I doubt it. You need a pretty big shuttle to deploy a stent+DPD, which would make for a pretty huge hole in the neck (and carotid). Also, going in that distal doesn't leave you much room to work, particularly in the ICA.

The issues are: 1) risk of dissection leading to stroke (bad), 2) risk of pseudoaneurysm leading to airway compromise (bad, seen it after CEA and required emergent surgical airway below the lesion), 3) cosmesis, 4) are you going to leave a sheath in there post-procedure?, 5) how do you hold pressure after the procedure?

 

[Strokeguy]

Direct carotid puncture used to be done in the older days (days of pneumoencephalography ..) for diagnostic angiograms. No one does it now for reasons mentioned by typhoonnegator.

 

[Hamhock]

Direct carotid puncture used to be done in the older days (days of pneumoencephalography ..) for diagnostic angiograms. No one does it now for reasons mentioned by typhoonnegator.

I have found that a major center is doing this frequently...and I am concerned for the reasons proposed above.

I have now seen one carotid case go uneventfully (meaning: no complication, but no benefit) and two go very badly. The worst was an ELECTIVE ica stent for presumed flow-dependent ischemia (infarction, really) that did not improve after the stent, but was complicated first by hematoma and then last second cric by ENT with suspected anoxic injury.

Clearly, I have some bias and suspicion regarding this procedure; but I am honestly still interested if I am an outlier here.

Anyone else in this forum who has seen success >> catastrophe with such a procedure ?

Does anyone know of any evidence supporting this maneurver?

HH

 

[Blue Rover]

Guimaraens L, Theron J, Casasco A, Cuellar H. Carotid artery stenting by direct percutaneous puncture. J Vasc Surg. 2011 Jul;54(1):249-51. PMID:21315547

The authors used a 6Fr Angioseal at the end of the case for hemostasis. I would personally have used direct exposure, a suture mediated device (e.g., Proglide), or at least something extravascular (e.g., StarClose). The possibility of that footplate dislodging and flying distally into the MCA gives me pause.

 

[Strokeguy]

The question here is not about the closure device. It is rare to perform direct carotid puncture. There has to be a damn good reason to do it; and not a femoral or radial access.
Even the most high volume centers wouldn't be doing many or any such cases.

 

[Blue Rover]

One reason to perform direct carotid puncture when performing CAS is to avoid the risk of embolization from manipulation of wires, catheters, or sheaths in the frequently atheosclerotic aortic arch.

This benefit, of course, is purely theoretical, but the mechanism is appealing. I can't speak to what happened at the OP's institution, and I haven't percutaneously punctured any carotid arteries myself (nor have I heard of anyone at my institution doing so). Improvement in CAS will occur only with well conducted research into potentially innovative (but risky) techniques.

Finally, I think closure is a very important part of the discussion. Posts #3 and #5 describe complications that are directly related to closure failures.