CASE 11119 Published on 10.07.2013
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Snare-assisted trans-brachial stenting of internal carotid artery in a patient affected by Leriche\'s Syndrome

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Gandini Roberto; Del Giudice Costantino; Salvatori Eva; Morini Marco; Loreni Giorgio; Pampana Enrico; Simonetti Giovanni.

Policlinico Tor Vergata, Fondazione PTV;
Diagnostic Imaging, Molecular Imaging,
Radiotherapy and Interventional Radiology Department;
Viale Oxford 81 00133
Rome, Italy;
Email:costantino.delgiudice@gmail.com
Connected authors
Patient

72 years, male

Categories
Area of Interest Arteries / Aorta ; Imaging Technique Catheter arteriography
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Clinical History
A 72 years-old man, with a symptomatic severe right internal carotid artery stenosis and aorto-iliac occlusion (Leriche's Syndrome), was deemed unfit for surgical thromboendarterectomy intervention (TEA) due to several comorbidities (hypertension, DM type II, dislipidaemic, use of anticoagulants).
We present an alternative endovascular approach.
Imaging Findings
After imaging study, Patient was scheduled for an endovascular attempt.
Leriche's syndrome made it essential to use a trans-brachial approach, which was properly executed (Fig. 1).
During the positioning of the coaxial catheters with two 0.014 guidewires in the right external and internal carotid arteries, the system was unstable dropping down in the aortic arch (Fig.1 c).
To solve the instability of the system, a right transbrachial access was added and a GooseNeck-Snare system (ev3/Micro Therapeutics , Irvine, USA) was used in order to catch the contralateral guidewire to maintain tension and stabilise the system (Fig. 2a,b). In this way the advancement, positioning and deployment of the stent became feasible (Fig. 3a,b). First, a Spider cerebral protection device (ev3/Micro Therapeutics) was placed and a 8.0 x 20-mm SMARTer balloon-expandable stent (Cordis) was subsequently deployed.
The post-procedural control documented the restoration of vessel patency (Fig. 3 c).
Discussion
The femoral artery is a large vessel calibre which allows an easy and safe insertion of catheters larger than 7 French, so the femoral approach remains the primary and optimal access route for interventional procedures. [1]
In case of severe aorto-iliac disease, recent aorto-femoral bypass grafts and aberrant arch vessels origins, the retrograde femoral pathway to the common carotid artery can be difficult or impossible. [2]
In our case Leriche's Syndrome makes another approach mandatory, so a brachial access was adopted. [3, 4]
The increased availability of low-profile sheaths allowed an ever more frequent use of trans-brachial approach, which makes excellent accesses possible and is becoming popular among interventional radiologists. [5, 6]
Because the relative safety of using a brachial approach to perform carotid stenting remains unknown, this technique is best reserved for experienced carotid stent operators in situations where carotid revascularisation is deemed essential and alternate options are absent. [7, 8]
The tortuous path of the catheters from the brachial artery to the common carotid artery can make indispensable the use of a technique in order to make the system stable, which may be at risk of displacement during the procedure. Our first attempt was to place two guidewires into the external and internal carotid arteries in order to stabilise the system but the failure of the attempt made us employ the gooseneck snare. This alternative solution was realised with the purpose of keeping the system in tension and to safely advance the carotid stent.
So the interventional radiology was able to move forward, place and release the stent at the site of the stenosis. [6, 9]
Due to the condition of the patient an endoluminal approach has been chosen for a better risk-benefit ratio. CAS (Carotid artery stenting) is an acceptable alternative to CEA (Carotid endoarterectomy), particularly for patients who are at high surgical risk. However, patients’ preferences and anatomy must also be taken into consideration. [10, 11]
Differential Diagnosis List
Right internal carotid artery stenosis
Carotid artery dissection
Takayasu arteritis
Final Diagnosis
Right internal carotid artery stenosis
Case information
URL: https://www.eurorad.org/case/11119
DOI: 10.1594/EURORAD/CASE.11119
ISSN: 1563-4086
Figure 1

Fig. 1

Fig. 1
(A) The diagnostic angiography showed the right internal carotid stenosis in the proximal III. (B) Two guidewires were placed, in the external and internal carotid artery. (C) The system dropped down in the aortic arch.
Figure 2

Fig. 2

Fig. 2
(A) The GooseNeck-Snare system was used in order to catch the contralateral guidewire (B) The guidewire was kept from the right trans-brachial approach to maintain the system in tension
Figure 3

Fig. 3

Fig. 3
(A) The SMARTer stent was advanced over the cerebral protection device in the internal carotid artery; (B) The balloon-expandable stent was deployed; (C) The final angiographic control documented treated vessel patency