Direct percutaneous carotid access for carotid angioplasty and stenting

To describe a direct percutaneous carotid access technique for carotid artery stenting (CAS) that circumvents the potential for embolization that can occur during catheter manipulation in the aortic arch during femoral access.

After inducing anesthesia, an ultrasound transducer is placed at the base of the neck above the clavicle. A 21-G, 7-cm needle from a micropuncture introducer is used for single-wall puncture of the common carotid artery (CCA). A 0.018-inch guidewire is inserted into the needle for placement of a 4-F, 10-cm introducer. After placing a 0.035-inch angled guidewire in the external carotid artery, the 4-F introducer is exchanged for the closure device sheath (preclose technique). A regular 6-F introducer is then placed inside the closure device sheath, and a low dose (2000 units) of heparin is administered for the brief CAS procedure, which is performed under cerebral protection. After a successful procedure is confirmed, the protection device is retrieved, and the closure device is applied to seal the puncture.

This approach has a low rate of neurological and access site complications. Percutaneous direct carotid access could extend the indications for CAS to include difficult anatomies, high-risk patients, and certain emergent situations that warrant easy and rapid access to the CCA.