Introduction. Case Presentation

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1 Journal of Neuroendovascular Therapy 08; : 5 56 Online ugust 8, 07 OI: /jnet.tn Left ervical Internal arotid rtery Stenting via the Left rachial rtery in Which a Simmons-type Guiding Sheath Was ombined with a Guiding atheter Masaru biko, Shigeyuki Sakamoto, Junichiro Ochiai, Naoto Yamada, Kazuhiko Kuroki, and Kaoru Kurisu Purpose: We report a patient who underwent left carotid artery stenting (S) via the left brachial artery. ase Presentation: The patient was a 7-year-old male with symptomatic stenosis of the left cervical internal carotid artery. He had undergone axillo-axillo bypass for occlusion of the right subclavian artery. He also had a history of arteriosclerosis obliterans of the bilateral lower limbs. transbrachial approach was adopted. To increase the intensity of the flexible part of a Simmons-type guiding sheath, a guiding catheter was combined. The guiding sheath was guided/ inserted into the left common carotid artery, and S was accomplished. onclusion: The combination of a Simmons-type guiding sheath and guiding catheter for increasing the intensity of the former s flexible part was effective when inserting the guiding sheath into the left common carotid artery during left S via the left brachial artery. Keywords stenosis of the left cervical internal carotid artery, stenting, transbrachial approach Introduction ervical internal carotid artery stenting (S) is commonly performed using a transfemoral approach. 3) Transbrachial 4 8) or radial 9 ) artery routes are selected in accordance with the states of access routes through the femoral artery (femoral artery, iliac artery, aorta, aortic arch, and common carotid artery). s the side of puncture, the right side is routinely selected, and the left side is rarely selected as a first option due to the complexity of/difficulty in surgical procedures. epartment of Neurosurgery, Graduate School of iomedical and Health Sciences, Hiroshima University, Hiroshima, Hiroshima, Japan epartment of Neurosurgery, J Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan Received: May 3, 07; ccepted: July 5, 07 orresponding author: Masaru biko. epartment of Neurosurgery, Graduate School of iomedical and Health Sciences, Hiroshima University, --3 Kasumi, Minami-ku, Hiroshima, Hiroshima , Japan tenmab_s@yahoo.co.jp This work is licensed under a reative ommons ttribution-nonommercial- Noerivatives International License. 08 The Japanese Society for Neuroendovascular Therapy In this study, we performed S through the left brachial artery for symptomatic stenosis of the left cervical internal carotid artery, as the access route was limited to the left brachial artery due to a history of peripheral vascular disorder of the limbs. The angle between the left subclavian and left common carotid artery origins was sharp, and the procedure was considered to be difficult. However, to increase the intensity of the flexible part of a Simmons-type guiding sheath (xcelguide MSK 6 Fr: Medikit o., Ltd., Tokyo, Japan), a guiding catheter (Envoy Simmons 6 Fr: Johnson & Johnson, Miami, FL, US) was combined. fter the guiding sheath was inserted into the left common carotid artery, S was accomplished. We report the present case, and review the literature. ase Presentation ase: 7-year-old male. omplaint: transient right incomplete hemiplegia. Medical history: He had undergone axillo-axillo bypass for occlusion of the right subclavian artery and right femoropopliteal bypass for arteriosclerosis obliterans (SO) of the right lower limb. Furthermore, surgery for SO of the left lower limb had been scheduled. He had undergone coronary stenting for myocardial infarction. 5

2 Effectiveness of ombination of Simmons-type Sheath and atheter Fig. () Preoperative MR showed moderate stenosis at the left cervical internal carotid artery (arrow). () T showed patency of axillo-axillo bypass, and short distance and acute angle from left subclavian artery origin to left common carotid artery origin. Present illness: On 06, right incomplete hemiplegia persisted for hour, and the patient was referred from the epartment of ardiology to the epartment of Neurosurgery. Neither cephalic T nor MRI revealed any cerebral hemorrhage or acute-phase cerebral infarction, but cervical MR showed moderate stenosis of the left cervical internal carotid artery, leading to a diagnosis of a transient cerebral ischemia attack related to the lesion. ccording to the North merican Symptomatic arotid Endarterectomy Trial (NSET) method, the stenosis rate was 60%, suggesting symptomatic stenosis of the cervical internal carotid artery. Surgery was indicated. s he had a history of myocardial infarction, internal carotid artery endarterectomy was avoided. For the right femoral artery, bypass had been performed, and the wall of the right external iliac artery was markedly irregular on 3 T; puncture was considered to be dangerous. Puncture of the left femoral artery was impossible before surgery for SO based on evaluation by the epartment of ardiovascular Surgery. In addition, the right subclavian artery was also occluded; therefore, left S through the left brachial artery was planned. Neurologic findings on admission: Not contributory. Oral drugs: spirin at 00 mg, clopidogrel at 75 mg, atorvastatin at 0 mg, and vonoprazan fumarate at 0 mg. Imaging findings on admission: MR of the head and neck revealed moderate stenosis of the left cervical internal carotid artery (Fig. ). T confirmed moderate stenosis of the left cervical internal carotid artery and the patency of axillo-axillo bypass. The distance between the left common carotid and left subclavian artery origins was short, and the angle was sharp (Fig. ). Endovascular surgery: Under local anesthesia with % lidocaine, the left brachial artery was punctured using an 8G indwelling needle inch Radifocus guide wire half-stiff 80 cm (Terumo orporation, Tokyo, Japan) was inserted, and dilated with a dilator. Subsequently, an xcelguide MSK 6 Fr cm was guided to the left subclavian artery. t this point, systemic heparinization was performed. n Inner was removed, and an Envoy Simmons 6 Fr 00 cm was inserted to increase the intensity of the flexible part of the xcelguide MSK 6 Fr. 4 Fr contrast enhancement catheter measuring 30 cm was inserted into the Envoy Simmons 6 Fr. The guide wire was returned at the aortic valve to form the Simmons shape of the 4 Fr contrast enhancement catheter, and the tip was guided to the aortic arch to descending aorta. fter the guide wire was guided to the descending aorta, a contrast enhancement catheter was inserted, followed by an xcelguide MSK 6 Fr and Envoy Simmons 6 Fr. The tip of the xcelguide MSK 6 Fr was inserted into the descending aorta. When the flexible part of the Simmons shape was guided to the aortic arch, the guide wire was removed, and the Simmons shape was formed in the ascending aorta by pushing the xcelguide MSK 6 Fr and Envoy Simmons 6 Fr (Fig. ). The xcelguide MSK 6 Fr tip was guided to the origin of the left common carotid artery (Fig. ), and placed there. The Envoy Simmons 6 Fr was removed (Fig. and ). Filter Wire EZ (Stryker, Kalamazoo, MI, US) was carefully crossed with the lesion, and developed in the high-position internal carotid artery at the distal stenotic site. Endovascular ultrasonography confirmed the proximal and distal stenotic sites measuring and mm, respectively. fter predilation with a Sterling mm (oston Scientific, oston, M, US), a arotid Wallstent 8 mm (Stryker) was developed (Fig. 3), and postdilation was performed using a Sterling 6 40 mm (Fig. 3). Endovascular ultrasonography confirmed the absence of protrusion in the stent and favorable dilation (Fig. 3 and 3). uring this procedure, 53

3 biko M, et al. Fig. () Fluoroscopic view showed that U shape of xcelguide MSK 6 Fr (Medikit o., Ltd., Tokyo, Japan) and Envoy Simmons 6 Fr (Johnson & Johnson, Miami, FL, US) was made in the ascending aorta. () Fluoroscopic view showed that xcelguide MSK 6 Fr and Envoy Simmons 6 Fr were navigated into the left common carotid artery origin. () Fluoroscopic view showed that xcelguide MSK 6 Fr and Envoy Simmons 6 Fr were cannulated into the left common carotid artery. () Left carotid artery angiogram before S showed moderate stenosis in left internal carotid artery. S: carotid artery stenting Fig. 3 () Fluoroscopic view showed stent deployment. () Fluoroscopic view showed postdilatation. () P view of final carotid artery angiogram shows improvement of the stenosis. () Lateral view of final carotid artery angiogram shows improvement of the stenosis. P: anterior-posterior the xcelguide MSK 6 Fr was stable on guiding each device, with no falling from the origin of the left common carotid artery to the aortic arch. ourse after embolization: Postoperative diffusion-weighted images did not show any new high-signal-intensity area. There was no new neurologic deterioration, and the patient was discharged 7 days after surgery. iscussion When selecting a transbrachial approach for S, the right brachial artery is routinely adopted, and the left brachial artery is rarely selected as a first option. Various studies have reported S procedures using a transbrachial approach. Success or failure depends on whether a guiding sheath 6 Fr can be guided to the common carotid artery or whether the stability of the guiding sheath can be obtained during the procedure. 6,8 ) When performing left S through the right brachial artery, it may be difficult to guide a guiding sheath to the standard-shape aortic arch (especially type I arch), 54

4 Effectiveness of ombination of Simmons-type Sheath and atheter Fig. 4 () xcelguide MSK (Medikit o., Ltd., Tokyo, Japan) connected with Goodtec Y-connector (Goodman o., Ltd., ichi, Japan) and () ENVOY Simmons 6 Fr (Johnson & Johnson, Miami, FL, US), 00 cm. () Simmons shape of xcelguide MSK and () Simmons shape of ENVOY Simmons. () n ENVOY Simmmons 6 Fr 00 cm was inserted into an xcelguide MSK connected with Goodtec Y-connector. () Simmons shape of an xcelguide MSK in the situation that an ENVOY Simmmons 6 Fr 00 was inserted into an xcelguide MSK connected with Goodtec Y-connector. depending on the bifurcation angle of the common carotid artery. 9 ) This is because the force is loaded in the aortic direction (inferior direction) on guiding a guiding sheath or device for stenting. The left common carotid artery originates from the aortic arch toward the immediately above to left superior sides (not the right side); therefore, when performing left S through the left brachial artery, as demonstrated in our patient, the force in the aortic direction (inferior direction) is great, making the guiding of a guiding sheath and stabilization during the procedure difficult. n xcelguide MSK 6 Fr cm is a Simmonstype guiding sheath measuring 90 cm in effective length, inch in inner diameter, and 7.5 cm in tip length (Fig. 4 and 4). n Envoy Simmons 6 Fr 00 cm is a Simmons-type guiding catheter measuring 05.5 ± cm in entire length, 00 cm in effective length, inch in inner diameter, and 0 cm in flexible tip length, with a 5-grade flexible structure body (Fig. 4 and 4). When connecting an xcelguide MSK 6 Fr to a GOOTE Y-connector (Goodman o., Ltd., ichi, Japan) and inserting an Envoy Simmons 6 Fr 00 cm, the xcelguide MSK 6 Fr tip became flush with the Envoy Simmons 6 Fr 00 cm tip, and the Simmons shape of the xcelguide MSK 6 Fr was maintained (Fig. 4 and 4). In the present case, it was relatively easy to guide the tip of the Simmons shape formed in the ascending aorta to the left common carotid artery. However, when guiding a Simmons-type diagnostic catheter to the target blood vessel, the flexible part of the catheter may break. oncerning the xcelguide MSK 6 Fr, similar episodes may also occur. To prevent this, we protected the flexible part of the xcelguide MSK 6 Fr by combining an Envoy Simmons 6 Fr guiding catheter to increase the intensity of the flexible part, thus successfully guiding it to the left common carotid artery. The lumen was maintained even after the Envoy Simmons 6 Fr was removed. Furthermore, a 7.5-cm area of the xcelguide MSK 6 Fr from the flexible part was inserted into the common carotid artery, making it possible to guide each device stably. On the other hand, as a precaution, the tip of an Envoy Simmons 6 Fr used to increase the intensity of the flexible part of an xcelguide MSK 6 Fr becomes flush with the tip of the xcelguide MSK 6 Fr. Therefore, distal embolism related to the insertion of the tip of a relatively large-diameter catheter into the origin of the left common carotid artery must be considered. For S with a transbrachial approach, a guiding sheath may fall into the aorta on guiding each device (percutaneous transluminal angioplasty [PT] balloon, stent, endovascular ultrasonic probe). onsidering this risk, it is important to confirm the guiding of each device under fluoroscopy. When performing left S through the left brachial artery, the angle of the route from the left subclavian artery 55

5 biko M, et al. to the left common carotid artery is sharp, and it may be difficult to guide a guiding sheath to the periphery of the left common carotid artery, or the stability during the procedure may be affected. Using this procedure, we maintained the intensity of the flexible part of an xcelguide MSK 6 Fr, and successfully guided a guiding sheath to the left common carotid artery. This procedure may be useful for performing left S through the left brachial artery. onclusion We encountered a patient who underwent left S through the left brachial artery. This method, in which an Envoy Simmons 6 Fr guiding catheter was combined to increase the intensity of the flexible part of an xcelguide MSK 6 Fr guiding sheath, was useful for left S through the left brachial artery. isclosure Statement There is no conflict of interest to be disclosed regarding this article for the main author and coauthors. References ) rott TG, Hobson RW, Howard G, et al: Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 00; 363: 3. ) Matsuda Y, Terada T, Masuo O, et al: The clinical results of transcervical carotid artery stenting and frequency chosen as the approach route of carotid artery stenting in,067 consecutive cases. cta Neurochir (Wien) 03; 55: ) Yadav JS, Wholey MH, Kuntz RE, et al: Protected carotidartery stenting versus endarterectomy in high-risk patients. N Engl J Med 004; 35: ) kaji K, Tanizaki Y, Hiraga K, et al: [ case of carotid stenting via the transbrachial approach in the bovine arch]. No Shinkei Geka 006; 34: (in Japanese) 5) Nanto M, Tsuura M, Takayama M, et al: [arotid artery stenting via a transbrachial artery: techniques and problems]. No Shinkei Geka 007; 35: (in Japanese) 6) Sakamoto S, Mitsuhara T, Kajihara Y, et al: [Left carotid artery stenting via transbrachial artery approach by using coaxial system with SHI FUUKI ilator 6Fr and ENVOY Simmons 6Fr]. JNET 05; 9: 5. (in Japanese) 7) Wu J, heng I, Hung W, et al: Feasibility and safety of transbrachial approach for patients with severe carotid artery stenosis undergoing stenting. atheter ardiovasc Interv 006; 67: ) Matsumoto H, Masuo O, Takemoto H, et al: [arotid artery stenting via the transbrachial approach]. JNET 007; : (in Japanese) 9) Mendiz O, Sampaolesi H, Londero HF, et al: Initial experience with transradial access for carotid artery stenting. Vasc Endovascular Surg 0; 45: ) Hayakawa M, Takigawa T, Kamiyama Y, et al: [arotid artery stenting via the transradial approach: a single-center experience]. JNET 0; 6: 6 4. (in Japanese) ) Pinter L, agiannos, Ruzsa Z, et al: Report on initial experience with transradial access for carotid artery stenting. J Vasc Surg 007; 45: