Abstract
Objectives
To evaluate carotid artery stenting (CAS) procedures with or without a new dedicated guiding catheter in anatomically challenging aortic arches in our experience.
Methods
We retrospectively reviewed 172 procedures of CAS performed from December 2006 to October 2011 in 159 consecutive patients (100 men, mean age 78 years): 15 patients had type III aortic arch, 13 had a bovine aortic arch, 6 had an acute angle at the origin of the left common carotid artery from the aortic arch, 2 had type III aortic arch with bovine aortic arch, and 1 had a bicarotid trunk with an aberrant right subclavian artery. In this group of difficult anatomy (37 cases), CAS was performed with (13 cases) or without (24 cases) a new dedicated guiding catheter.
Results
Mean time of fluoroscopy (16 min vs. 18 min, P < 0.01), mean total procedural time (68 min vs. 83 min, P < 0.001), technical failure (0/13 vs. 3/24 cases, P = 0.01), clinical failure (0/13 vs. 4/21 cases, P = 0.02) and local complications (0/13 vs. 2/24 cases, P < 0.0001) were significantly lesser in the dedicated guiding catheter group.
Conclusions
The new dedicated guiding catheter may be more effective and less risky for CAS in anatomically challenging aortic arches.
Key Points
• Complex anatomy of the aortic arch is not rare
• Endovascular carotid artery stenting (CAS) is more difficult when the anatomy is complex
• A new dedicated guiding catheter may help CAS when the arch anatomy is complex
• The new dedicated guiding catheter may be less risky in complex arches
Similar content being viewed by others
References
Yadav JS, Wholey MH, Kuntz RE et al (2004) Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Eng J Med 351:1493–1501
Zarins CK, White RA, Diethrich EB, Shackelton RJ, Siami FS (2009) Carotid revascularization using endarterectomy or stenting systems (CaRESS): 4-year outcomes. J Endovasc Ther 16:397–409
Macdonald S (2012) Carotid artery stenting trials: conduct, results, critique, and current recommendations. Cardiovasc Intervent Radiol 35:15–29
Beckett D, Gaines PA (2008) Lessons from EVA-3S and SPACE. Cardiovasc Intervent Radiol 31:5–7
Ederle J, Bonati LH, Dobson J et al (2009) Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long term follow-up of a randomised trial. Lancet Neurol 8:898–907
Ederle J, Dobson J, Featherstone RL et al (2010) Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 375:985–997
Sadek M, Hynecek RL, Sambol EB, Ur-Rehman H, Kent KC, Faries PL (2008) Carotid angioplasty and stenting, success relies on appropriate patient selection. J Vasc Surg 47:946–951
Ederle J, Featherstone RL, Brown MM (2009) Randomized controlled trials comparing endarterectomy and endovascular treatment for carotid artery stenosis: a Cochrane systematic review. Stroke 40:1373–1380
Liu Z, Shi Z, Wang Y et al (2009) Carotid artery stenting versus carotid endarterectomy: systematic review and meta-analysis. World J Surg 33:586–596
Brahmanandam S, Ding EL, Conte MS, Belkin M, Nguyen LL (2008) Clinical results of carotid artery stenting compared with carotid endarterectomy. J Vasc Surg 47:343–349
Murad MH, Flynn DN, Elamin MB et al (2008) Endarterectomy vs stenting for carotid artery stenosis: a systematic review and meta-analysis. Vasc Surg 48:487–493
Luebke T, Aleksic M, Brunkwall J (2007) Meta-analysis of randomized trials comparing carotid endarterectomy and endovascular treatment. Eur J Vasc Endovasc Surg 34:470–479
Qureshi AI, Kirmani JF, Divani AA, Hobson RW 2nd (2005) Carotid angioplasty with or without stent placement versus carotid endarterectomy for treatment of carotid stenosis: a meta-analysis. Neurosurgery 56:1171–1179
Wholey MH, Wu WC (2009) Current status in cervical carotid artery stent placement. J Cardiovasc Surg (Torino) 50:29–37
Sidawy AN, Zwolak RM, White RA, Siami FS, Schermerhorn ML, Sicard GA (2009) Risk-adjusted 30-day outcomes of carotid stenting and endarterectomy: results from the SVS Vascular Registry. J Vasc Surg 49:71–79
Lal BK, Brott TG (2009) The carotid revascularization endarterectomy vs. stenting trial completes randomization: lessons learned and anticipated results. J Vasc Surg 50:1224–1231
Natsis KI, Tsitouridis IA, Didagelos MV, Fillipidis AA, Vlasis KG, Tsikaras PD (2009) Anatomical variations in the branches of the human aortic arch in 633 angiographies: clinical significance and literature review. Surg Radiol Anat 31:319–323
Chahwan S, Miller MT, Kim KA, Mantell M, Kirksey L (2006) Aberrant right subclavian artery associated with a common origin of carotid arteries. Ann Vasc Surg 20:809–812
Berko NS, Jain VR, Godelman A, Stein EG, Ghosh S, Haramati LB (2009) Variants and anomalies of thoracic vasculature on computed tomographic angiography in adults. J Comput Assist Tomogr 33:523–528
Zamir M, Sinclair P (1991) Origin of the brachiocephalic trunk, left carotid, and left subclavian arteries from the arch of the human aorta. Investig Radiol 26:128–133
Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS (2006) Bovine aortic arch variant in humans: clarification of a common misnomer. AJNR Am J Neuroradiol 27:1541–1542
Jakanani GC, Adair W (2010) Frequency of variations in aortic arch anatomy depicted on multidetector CT. Clin Radiol 65:481–487
Rielly JP (2008) Intrathoracic carotid bifurcation in Klippel-Feil syndrome. J Vasc Surg 47:1071–1073
Faggioli GL, Ferri M, Freyrie A et al (2007) Aortic arch anomalies are associated with increased risk of neurological events in carotid stent procedures. Eur J Vasc Endovasc Surg 33:436–441
Naggara O, Touzé E, Beyssen B et al (2011) Anatomical and technical factors associated with stroke or death during carotid angioplasty and stenting: results from the endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial and systematic review. Stroke 42:380–388
Cardaioli P, Rigatelli G, Ronco F, Dell’Avvocata F, Giordan M (2009) Carotid artery angioplasty and stenting in patients with hostile anatomy: the multi-wire technique. J Endovasc Ther 16:649–651
Shaw JA, Gravereaux EC, Eisenhauer AC (2003) Carotid stenting in the bovine arch. Catheter Cardiovasc Interv 60:566–569
Montorsi P, Galli S, Ravagnani P et al (2009) Carotid stenting through the right brachial approach for left internal carotid artery stenosis and bovine aortic arch configuration. Eur Radiol 19:2009–2015
Berko NS, Haramati LB (2010) Letter to the editor re: “carotid stenting through the right brachial approach for left internal carotid artery stenosis and bovine aortic arch configuration”. Eur Radiol 20:816–817
Choi HM, Hobson RW II, Goldstein J et al (2004) Technical challenges in a program of carotid artery stenting. J Vasc Surg 40:746–751
Macdonald S, Lee R, Williams R, Stansby G (2009) Towards safer carotid artery stenting: a scoring system for anatomic suitability. Stroke 40:1698–1703
Stockx L (2006) Techniques in carotid artery stenting. Eur J Radiol 60:11–13
Folmar J, Sachar R, Mann T (2007) Transradial approach for carotid artery stenting: a feasibility study. Catheter Cardiovasc Interv 69:355–361
Patel T, Shah S, Ranjan A, Malhotra H, Pancholy S, Coppola J (2009) Contralateral transradial approach for carotid artery stenting: a feasibility study. Catheter Cardiovasc Interv 75:268–275
Coppi G, Moratto R, Veronesi J, Nicolisi E, Silingardi R (2010) Facilitating access to the supraortic vessels during carotid artery stenting: preliminary clinical experience with a new device and technique. J Am Coll Cardiol 56:B47, TCT-200
Saad G, Maertens A (2010) A novel method to reduce the risk of post-CAS stroke in the elderly. J Am Coll Cardiol 56:B47, TCT-202
Sakamoto S, Shibukawa M, Tani I et al (2011) Carotid artery stenting in a patient with right-sided aortic arch with an aberrant left subclavian artery. Acta Neurochir (Wien) 153:2169–2173
Solomon B, Berland T, Cayne N, Rockman C, Veith FJ, Maldonado T (2010) The coronary technique for complex carotid artery stenting in the setting of complex aortic arch anatomy. Vasc Endovasc Surg 44:572–575
Fang HY, Chung SY, Sun CK et al (2010) Transradial and transbrachial arterial approach for simultaneous carotid angiographic examination and stenting using catheter looping and retrograde engagement technique. Ann Vasc Surg 24:670–679
Criado FJ (2007) Endovascular techniques for supra-aortic trunk intervention. Perspect Vasc Surg 19:231–237
Kawarada O, Yokoi Y, Takemoto K, Morioka N (2007) Double-wire technique in balloon-protected carotid artery stenting. J Interv Cardiol 20:55–62
Gupta K, Biria M, Mortasavi A (2008) A modified technique for carotid cannulation. Tex Heart Inst J 35:286–288
Beitzke D, Wolf F, Edelhauser G et al (2011) Computed tomography angiography of the carotid arteries at low kV settings: a prospective randomized trial assessing radiation dose and diagnostic confidence. Eur Radiol 21:2434–2444
Kramer H, Runge VM, Morelli JN et al (2011) Magnetic resonance angiography of the carotid arteries: comparison of unenhanced and contrast enhanced techniques. Eur Radiol 21:1667–1676
European Carotid Surgery Trialists’ Collaborative Group (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351:1379–1387
North American Symptomatic Carotid Endarterectomy Trial Collaborators (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 339:1415–1425
Kaadir S (1991) Regional anatomy of the thoracic aorta. In: Kaadir S (ed) Atlas of normal and variant angiographic anatomy. Saunders, Philadelphia, pp 19–21
Linfante I, Andreone V, Akkawi N, Wakhloo AK (2009) Internal carotid artery stenting in patients over 80 years of age: single-center experience and review of the literature. J Neuroimaging 19:158–163
Acknowledgment
The authors thank Elisabetta Balestro for her English assistance with the preparation of this article.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Barbiero, G., Cognolato, D., Casarin, A. et al. Carotid artery stenting in difficult aortic arch anatomy with or without a new dedicated guiding catheter: preliminary experience. Eur Radiol 23, 1420–1428 (2013). https://doi.org/10.1007/s00330-012-2708-7
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-012-2708-7