New pull-through technique using the superficial temporal artery for transbrachial carotid artery stenting

Carotid artery stenting (CAS) is an effective and less invasive alternative to carotid endarterectomy for internal carotid artery (ICA) stenosis, but the guiding catheter is often technically difficult to introduce into the common carotid artery (CCA) in patients with concomitant atherosclerotic disease in the peripheral vessels or aorta. A new pull-through technique between the superficial temporal artery (STA) and the brachial artery was used to deliver the guiding catheter into the CCA safely and steadily. An 83-year-old male presented with repeated transient left hemiparesis caused by severe stenosis of the origin of the right ICA. He also had severe systemic atherosclerotic disease with occlusion of the bilateral femoral arteries. The innominate artery branched at an acute angle from the aorta. Therefore, catheterization of the right CCA seemed to be impossible using a conventional approach. The guidewire introduced from the right STA was lassoed by a loop snare wire and pulled out of the left brachial artery, forming the pull-through system. The guiding catheter could be introduced into the CCA from the left brachial artery over this guidewire. Subsequently, successful stent placement was performed under the distal protection. This new technique may facilitate safe and stable CAS even in patients with a severely tortuous access route due to concomitant atherosclerotic disease.