A case report of left carotid artery stenting in a patient with bullous aortic arch via right brachial artery access Guo Lianrui, Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University Guo Lianrui, Gu Yongquan*, Tong Zhuang, Li Xuefeng, Guo Jianming, Gao Xixiang, Zhang Jian, Wang Zhonghao (Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China) [Abstract] In October 2013, a 63-year-old female with left carotid artery stenosis and history of left-sided cerebral infarction and frequent transient ischemic attack (TIA) was admitted to our department. A 63-year-old female with left carotid stenosis, a history of left-sided cerebral infarction and frequent transient ischemic attack (TIA), a bovine aortic arch on preoperative CTA, and severe stenosis at the beginning of the left internal carotid artery, which was not suitable for carotid endarterectomy at the C2 level. During the operation, a puncture through the right brachial artery access was performed under general anesthesia, a contrast catheter was selected into the left external carotid artery, a long F6 sheath was selected into the left common carotid artery with a stiffened guidewire to establish surgical access, and then balloon dilation and stenting of the carotid artery under the umbrella was routinely performed. The procedure was successful without any complications. At the 1-month postoperative follow-up, the TIA symptoms completely disappeared and the carotid ultrasound indicated a clear flow after stenting of the left internal carotid artery. We conclude that stenting via the right brachial artery approach is safe and feasible for the treatment of left internal carotid artery stenosis in patients with bovine aortic arch variation. [Keywords] internal carotid artery stenosis; carotid artery stenting; brachial access, bovine aortic arch; aortic arch anomaly carotid artery stenting via the right brachial access for left carotid stenosis in the bovine arch: a case report Guo Lianrui1, Gu yongquan2, Tong Zhu, Li Xuefeng, Guo Jianming, Zhang Jian, Wang Zhonggao Department of Vascular surgery, Xuanwu Hospital. Capital Medical University, Institute of Vascular Surgery of Capital Medical University. [Summary] A 63 year-old female patient suffered from stroke A 63 year-old female patient suffered from stroke and subsequent frequent transient ischemic attack (TIA) was treated with CAS in October, 2013 in our department. Preoperative CTA and Duplex revealed a tight stenosis of the left carotid artery in the bovine arch, but the high location of carotid lesion is not suitable for carotid endarterectomy. Using the right brachial artery as access, we performed CAS with a 6Fr long sheath advancing into the the left common carotid artery. device was positioned within the left internal carotid artery distal to the stenosis, then the lesion was routinely dilated, and followed by A Spider Embolic protection device was positioned within the left internal carotid artery distal to the stenosis, then the lesion was routinely dilated, and followed by satisfactory deployment of a self-expending Protege stent. Duplex showed a patent left carotid artery stent at one month follow-up. CAS via the right brachial artery for left carotid stenosis in the bovine arch appears feasible and Key Words] carotid artery stenosis, carotid artery stenting, transbrachial access, bovine arch, aortic arch abnormality Carotid artery stenting (CAS) has become the treatment of choice for high-risk patients undergoing carotid endarterectomy (CEA) [1]. The conventional transfemoral approach to CAS is safe and reliable, but in a very small number of patients with type III aortic arch or anatomic variations, CAS via this approach can be very difficult and prone to complications [2, 3], especially in bovine aortic arch patients with left internal carotid artery stenosis. In October 2013, we admitted a case of left internal carotid artery stenosis combined with bullous aortic arch variation, and we successfully performed CAS via the right brachial artery approach. 1 Clinical data Female, 63 years old, was admitted to the hospital with the main reason of “transient slurred speech with right-sided limb weakness for 6 months, aggravated for 3 months”. The patient had a history of cerebral infarction for three times in three years, all of which resolved after medication. Three months ago, he was found to have severe stenosis of the left internal carotid artery by vascular ultrasonography in a foreign hospital. Cranial MRI: multiple cerebral infarcts. He was given oral bye aspirin 100 mg once/d, clopidogrel 75 mg once/d, and atorvastatin calcium 20 mg once a night, with no improvement in symptoms. Past history: history of primary hypertension and diabetes mellitus for 10 years. No history of smoking. Admission examination: look, speech was not fluent, tongue extension in the center. Muscle strength of the right upper limb was grade 3 and that of the right lower limb was grade 5; left limb movement was normal. Laboratory examination: blood routine, urine routine, liver and kidney function were normal, hyperlipidemia. Ultrasound: severe stenosis of the left carotid artery with ulcerated plaque; CTA: the aortic arch was bullous; both common carotid arteries originated from the unnamed artery; the right subclavian artery was tortuous with moderate stenosis at the beginning (Figure 1, 2); the left internal carotid artery was severely stenosed at the beginning and the lesion was located at the level of C2 vertebrae (Figure 1). Transcranial Doppler (TCD): both anterior and posterior communicating arteries were not open. Left carotid artery stenting: the right brachial artery approach was chosen, and the Seldinger technique was used to successfully puncture the right brachial artery retrograde and place the F6 arterial sheath (Terumo), which was administered with heparin 5000 U. A 65 cm Cobra catheter (Cordis) was first used with a 0.035 inch/150 cm (Terumo) superslip guidewire to retrograde through the brachial artery The catheter and guidewire were selected to enter the left common carotid artery under the roadmap, and the 0.035-inch/260-cm stiffened superslip guidewire was replaced with a 0.035-inch/260-cm stiffened superslip guidewire, and the cephalic end entered the branch of the external carotid artery. The distal common carotid artery is delivered approximately 2 cm from the bifurcation, and the dilator and stiffened guidewire are withdrawn. A 0.014-inch/190-cm Pilot 150 guidewire (Boston, USA) was passed through the diseased segment of the internal carotid artery in the lateral view, along which a 5 mm-diameter Spider umbrella (EV3, USA) was inserted to reach the flat segment of the distal internal carotid artery. The left carotid lesion was pre-dilated, and then 1 Protege self-expanding nickel-titanium alloy stent (EV3, USA) 8-6-30 mm was implanted in the exact position under the road map. Finally, the left internal carotid artery was restored to patency on imaging, and the blood flow in the left cerebral hemisphere was significantly improved compared with the preoperative one. No sign of embolus dislodgement was monitored by intraoperative TCD, and the cerebral blood flow in the left middle cerebral artery increased more than 100% compared with the preoperative basal value after stent release, and the increase in cerebral blood flow could be controlled within 100% by strictly controlling the systolic pressure at 100-110 mm Hg. The patient’s speech and limb motor functions were normal after awakening, and aspirin, Bolivar and Lipitor were continued to be given. On the second postoperative day, the patient showed drowsiness, but the physical examination was normal for speech, tongue extension was in the center, muscle strength of the right upper limb was grade 3 (the same as before surgery), and muscle strength of the remaining limbs was grade 5; pathological signs (). Brain MRI suggested multiple old lacunar cerebral infarct lesions. Blood pressure was strictly controlled and completely normalized on the 4th postoperative day. He was discharged from the hospital on the 6th postoperative day. At 1-month postoperative follow-up, no further TIA occurred, and carotid ultrasound suggested patency. 2 Discussion Although CEA is now recognized as the treatment of choice for carotid stenosis, CAS has also evolved as an indispensable treatment for carotid stenosis. Compared with CEA, the main advantage of CAS is that it is minimally invasive, avoiding complications such as cranial nerve injury and neck incision [1], and is suitable for patients with anatomic risk factors (e.g., contralateral carotid occlusion) and severe concomitant diseases (e.g., cardiac and pulmonary insufficiency), as well as postcarotid endarterectomy restenosis, contralateral recurrent laryngeal nerve injury, and a history of previous neck surgery or radiation therapy. In addition, CAS can treat full-length lesions of the carotid artery, especially those above C2 and below the clavicle that cannot be treated with CEA [1]. This case is a symptomatic carotid stenosis with a degree of 99% requiring surgical intervention; the stenosis is located at the level of C2, which is too high for CEA, and therefore, CAS is chosen. The key to performing CAS in the presence of anomalous aortic arch is the successful placement of a long sheath or guiding catheter to establish operative access, and at this point, the choice of the appropriate access is critical. The vast majority of CAS can be successfully performed via a femoral approach, but in this case with a bullous aortic arch, a left-sided CAS via a femoral approach would have been particularly difficult and prone to complications [2-4]. In this case, a transfemoral approach was attempted at an outside hospital, but was unsuccessful with multiple guidewires and catheters. Given that radial access has been successfully used for cardiac interventions, Patel et al [5] tried to perform carotid CAS via contralateral radial access, but the success rate of their left carotid was only 50% (4/8), which was significantly lower than the success rate of 100% (12/12) on the right side. Dahm et al [4] also used a right radial approach for CAS of left carotid stenosis in patients with bullous arches and achieved a success rate of 100% (4/4). Bakoyiannis et al [7] and Montorsi et al [8] also successfully attempted CAS of left carotid stenosis in patients with bullous arches via the right radial approach. Although CAS-related complications and puncture point complications did not occur in the small sample of studies by the aforementioned authors, the radial artery has a fine diameter, only 71.5% of women and 85.7% of men patients can fit into the F6 guiding catheter [9,10], and complications such as postoperative radial artery occlusion occur in 2.5% to 10% [11]. Tietke et al [3] attempted CAS with a brachial artery approach , which considered this approach safe and feasible, but their cases were all cases of severe stenosis of the iliac and femoral arteries or tortuous aortic arch, not patients with bovine aortic arch. In this case, we correctly chose the transverse right brachial artery approach and successfully completed CAS without any complications. Most of the operative accesses for CAS use F8 carotid guiding catheters [1, 2]. In this case, we used the F6 long sheath (ARROW) instead of the F8 guiding catheter to establish the access because, first, the brachial artery has a thin diameter and the use of a thinner sheath can reduce access-related complications; second, the ARROW long sheath has a longer dilator tip that can be easily shaped in vitro to enter the left common carotid artery through a bull’s-eye bend; third, the sheath of the long sheath and its internal dilator are complete sets of In this case, there is an obvious atherosclerotic plaque at the beginning of the right subclavian artery, which may lead to cerebral embolism once the plaque is dislodged. Once the operating channel is established, CAS can be performed in the usual way. CAS can be safely performed under local anesthesia in most cases, but in this case, the preoperative TCD indicates that both anterior and posterior communicating arteries are not open, lacking compensation, and frequent TIAs occur preoperatively, so if CAS is performed under local anesthesia, expansion of the lesion will cause ischemia and hypoxia in the brain on the side of the lesion, and the patient may even be at risk of sitting up suddenly during the operation due to cerebral consciousness disorder. The patient may even have the risk of sitting up suddenly during the operation due to cerebral impaired consciousness. In general anesthesia, the patient is intubated with a ventilator to inhale pure oxygen, and the partial pressure of blood oxygen is significantly increased, and the patient is in an unconscious state under general anesthesia, which can tolerate the temporary blockage of blood flow during carotid artery dilation well, and can safely control blood pressure to avoid preoperative hypoperfusion and postoperative hyperperfusion. Therefore, in this case, we chose to perform CAS under general anesthesia. CAS via the right brachial artery approach is safe and feasible for patients with left carotid stenosis in bovine aortic arch. References 1. Gurm HS, Yadav JS, Fayad P. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med,2008,358(15):1572- 2. Werner M, Bausback Y, Bräunlich S, Ulrich M, et al. Anatomic variables contributing to a higher periprocedural incidence of stroke and TIA in Catheter Cardiovasc Interv,2012,80(2):321-328. 3. 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