DOI: https://doi.org/10.21203/rs.3.rs-2255302/v1
Background
Common carotid artery occlusion (CCAO) is a rare cause of ischemic stroke and the major treatment for CCAO is bypass surgery. However, safer alternatives should be developed to treat CCAO.
Case presentation
A 68-year-old male was diagnosed with left-sided asymptomatic CCAO due to neck radiation therapy for laryngeal cancer. Recanalization therapy using a pull-through technique was initiated because cerebral blood flow progressively decreased during follow-up. First, after a short sheath was inserted into the common carotid artery (CCA), the occluded CCA was retrogradelypenetratedthrough the sheath. Second, a micro-guide wire was guided to the aorta from the femoral sheath where it was caught using a snare-wire guided from the cervical sheath. Subsequently, the micro-guide wire was gently pulled out from the cervical sheath, penetrated the occluded lesion, and was secured to the femoral and cervical sheaths. Finally, the occluded lesion was dilated using a balloon and the stent was placed. The patient was discharged uneventfully 5 days post-procedure.
Conclusions
Combined endovascular antegrade and direct retrograde carotid artery stenting is a versatile and minimally invasive treatment option for CCAO in terms of the reliable penetration of obstructive lesions and reduction of embolic and hemorrhagic complications.
The common carotid artery (CCA) is one of the major branches of the aorta. CCA occlusion (CCAO) is a rare (approximately 3%) cause of ischemic stroke, transient ischemic attack, and cerebral hypoperfusion.1,2 Although the natural history of CCAO is clearly revealed, over 90% of reported CCAO cases are symptomatic, and revascularization treatment is recommended. The major treatment for CCAO is bypass surgery, whereas endovascular treatment is reported in only 1% of the cases.2 Bypass surgery for CCAO is an established approach, and patency is reported to be over 90%. However, morbidity and mortality rates have been reported to be 6–31% and 6%, respectively1,2. A safe and versatile treatment strategy for CCAO is therefore needed but alternative strategies, including endovascular treatment for CCAO, have not been established. This study aimed to report the efficacy and benefits of combined endovascular antegrade and direct retrograde access as an alternative intervention for CCAO.
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).
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).
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.
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.
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).
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.
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.
This surgical case introduced a combined endovascular antegrade and direct retrograde access for CCAO. The concept of the pull-through technique is the reliable penetration of obstructive lesions and reduction of embolic and hemorrhagic complications.
An ideal treatment strategy for CCAO has not been established owing to the lack of randomized trials for CCAO. Beacuse of limited reports of surgically treated CCAO patients where most of them were symptomatic, the natural history of asymptomatic CCAO and the efficacy of medical treatment are unknown. With reference to ICA occlusion, symptoms and CBF impairment may be helpful for surgical indications3.
| Year | Age | Rile's classification | Side | Symptom | Etiology | Treatment | Direction | Detail | Stenting | Complication |
|---|---|---|---|---|---|---|---|---|---|---|
| 20074 | 60 | 1a | Right | TIA | Atherosclerosis | Combined | Retrograde | Ring-stripper (retrograde endarterectomy) | Yes (for the intimal flap) | None |
| 20095 | 56 | 1a | Left | Ischemic stroke | Occlusion of previous placed stent | Endovascular | Bidirectional | Retrograde PTA | No | None |
| 20106 | 64 | 1a | Left | Ischemic stroke | Atherosclerosis | Endovascular | Antegrade | Antegrade CAS | Yes | Asymptomatic embolism |
| 20167 | 41 | - | Bilateral | Ischemic stroke | Irradiation | Endovascular | Antegrade | Antegrade CAS | Yes | Transient and partial Horner's syndrome |
| 20208 | 71 | 1a | Right | TIA | Atherosclerosis | Endovascular | Antegrade | Antegrade CAS | Yes | None |
| 20208 | 53 | 1a | Left | TIA | Irradiation | Endovascular | Antegrade | Antegrade CAS | Yes | None |
| 2022 Present case | 68 | 1a | Left | None | Irradiation | Combined | Bidirectional | Combined | Yes | None |
| Abbreviations: CAS, carotid artery stenting; PTA, percutaneous transluminal angioplasty; TIA, transient ischemic attack | ||||||||||
Limited reports exist on antegrade and retrograde endovascular treatments for CCAO4,5,7. In reports of anterograde CAS for CCAO, the guide wire successfully passed through the occluded lesion via the catheter placed at the origin of the CCA6–8. According to previous cases, endovascular treatment for CCAO is also suitable for Rile’s classification type 1a, probably because it is necessary to connect normal vessels to other normal vessels. As Rile’s classification type 1a accounts for more than 60% of cases, endovascular treatment may be applicable to more than half of CCAO cases. However, reports on anterograde CAS for CCAO are limited because they are not versatile. The shorter the patent at the origin of the CCA, the more likely it is that the catheter will not be stable, thus providing less support for wire insertion through the lesion. Apart from uncertain penetration, antegrade CAS carries the risk of embolic complications because a distal protection device cannot be used during lesion penetration6,7. Therefore, establishment of a reliable and safe treatment method and selection of treatable lesions are required.
The present pull-through technique overcomes the uncertainty of penetration and absence of distal protection. The advantage of this technique is its versatility, regardless of the patent length of the origin of the CCA or tortuosity of the access route. In addition to the pull-through technique, combined endovascular antegrade and direct retrograde access enables strong support for lesion penetration, reduction of embolic complications by secure blockage of the distal blood flow, and reliable hemostasis by suturing the puncture site4,5. For certainty and safety, a hybrid strategy for the CCAO is recommended.
Combined endovascular antegrade and direct retrograde CAS is a promising endovascular treatment option for CCAO, allowing reliable penetration of obstructive lesions and reduction of embolic and hemorrhagic complications. Because combined endovascular antegrade and direct retrograde access is a versatile and minimally invasive treatment option for recanalization of CCAO, further study comparing medical treatment and bypass surgery is needed.
CAS: carotid artery stenting
CBF: cerebral blood flow
CCA: common carotid artery
CCAO: common carotid artery occlusion
ECA: external carotid artery
ICA: internal carotid artery
SPECT: single-photon emission computed tomography
Ethical Approval: This study was performed under the approval of the institutional research committee (142100603).
Informed consent: Informed consent was obtained from the participant included in the study.
Consent for publication: Consent for publication was obtained for the individual person’s data included in the study.
Availability of data and materials: Available
Conflict of Interest: The authors declare that they have no conflict of interest.
Funding: This study was not supported by any funding.
Authors' contributions: SM and YN conceived the study and designed the trial. SM, YN, TA, SI, WS, HK, and SS took care of the patient. TY supervised the conduct of the trial. All authors contributed substantially to its revision. SM takes responsibility for the paper as a whole.
Acknowledgments: We would like to express our gratitude to all the staff at our institutions for their support in the treatment. We would like to thank Editage (www.editage.com) for the English language editing.
Compliance with Ethical Standards: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional esearch committee (142100603) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.