Clinical presentation
The patient, a 68-year-old male, was referred to our hospital with an asymptomatic left CCAO, which was diagnosed at another clinic. His medical history included hypertension and neck radiation therapy for laryngeal cancer 10 years before admission. Single-photon emission computed tomography (SPECT) showed a progressive decrease in left cerebral blood flow (CBF) at the 1-year follow up, and recanalization therapy was initiated (Fig. 1A–D).
Surgical procedures
Direct approach for the carotid artery
Aspirin and clopidogrel were administered for 2 weeks before performing recanalization therapy via combined endovascular antegrade and direct retrograde access, under general anesthesia. First, the carotid bifurcation, internal carotid artery (ICA), external carotid artery (ECA), and superior thyroid artery were exposed via carotid endarterectomy (Fig. 2A). A purse-string suture was applied in advance at the puncture site of the ICA, 1 cm distal to the bifurcation. A 5Fr kink-resistant sheath was retrogradely inserted into the ICA through the skin (Fig. 2B).
Retrograde penetration of occlusion site
After heparinization, the occluded CCA was penetrated using a 4Fr Bernstein catheter and 0.035-inch angle-type Radifocus guide wire (Terumo, Japan). Despite the tough proximal end of the blockage, penetration was achieved by bringing the catheter closer and advancing the guide wire. Capture of the true lumen of the aorta was confirmed by the free movement of the guide wire and backflow of blood from the catheter.
Pull-through technique for the carotid occlusion
The right femoral artery was punctured and a 7Fr shuttle sheath (Cook Medical, United states) was inserted. A 0.014-inch micro-guide wire (ASAHI Spindle XS 0.7 300 cm, ASAHI Intecc, Japan) was guided to the aorta via femoral access, and then caught by a 10-mm goose neck snare (Medtronic, United States) guided in a 4Fr Berenstein catheter in the cervical sheath (Fig. 2C). After the ECA and ICA were temporally occluded with vessel tape, the micro-guide wire was gently extracted from the cervical sheath using the goose neck snare. Finally, the micro-guidewire was passed through the occluded lesion and secured to the femoral and cervical sheaths.
Antegrade percutaneous angioplasty and stenting
The occluded lesion was dilated using a 5.0-mm PTA balloon (RX Genity, Kaneka Medical Products, Japan), and the guiding sheath was sequentially advanced into the dilated vascular lumen. When the guiding sheath was advanced after PTA, the balloon was kept at low pressure, similar to an arrowhead (Fig. 2D). Gentle angiography was performed after the guiding sheath reached the carotid bifurcation to confirm the true and intact lumen. Three carotid Wallstents (Boston Scientific Limited, Ireland) were placed to overlap sequentially from the distal intact part to the proximal intact part of the CCA (Fig. 2E).
Antegrade reperfusion
Retrograde angiography of the cervical sheath confirmed that the stent was patent (Fig. 2F) and there was no thrombus in the stent. Finally, the blockages of the ECA and ICA were released, and antegrade reperfusion was confirmed. The cervical sheath was removed and the puncture site was secured using a purse-string suture. The procedure was completed by closing the cervical wound and removing the femoral sheath in a standard manner.
Outcome
After surgery, the patient had no neurological symptoms, and magnetic resonance imaging and SPECT showed improved CBF without ischemia or hyperperfusion. No swelling was observed at the cervical or inguinal puncture site. Five days posoperatively, the patient was discharged with a modified Rankin Scale score of 0. He did not experience subsequent re-occlusion or cerebral infarction.