Direct Carotid Puncture for Emergent Thrombectomy: 2-Dimensional Operative Video

Emergent thrombectomy for large vessel occlusion is now a standard procedure within neurosurgery. In general, thrombectomy is attempted via a femoral artery puncture. However, due to anatomic variability and arterial tortuosity, target vessels cannot be catheterized in roughly 5% of patients.1 Radial artery access is an alternative to femoral artery access; however, target arteries for thrombectomy cannot be catheterized via the femoral or radial arteries in a small subset of patients. Direct carotid puncture is an alternative route of access for emergent thrombectomy in acute stroke.2,3 In this video, we present a patient with an acute right middle cerebral artery occlusion who was taken for emergent thrombectomy after consenting for the procedure. Because of unfavorable arterial anatomy, the right internal carotid artery could not be successfully catheterized via femoral or radial arterial punctures. We ultimately catheterized the right internal carotid artery and middle cerebral artery via a direct carotid puncture. We review the technique for direct carotid puncture, and discuss the outcomes associated with this method of access in the setting of acute large vessel occlusion. We also discuss complications associated with direct carotid puncture. Direct carotid puncture is an acceptable bail-out technique in the setting of emergent thrombectomy when femoral and/or radial access is not possible. Figure at 2:18 republished from Sekhar LN, Iwai Y, Wright DC, Bloom M. Vein graft replacement of the middle cerebral artery after unsuccessful embolectomy: case report. Neurosurgery. 1993;33(4):723-727, by permission of the Congress of Neurological Surgeons. Table at 6:05 modified from Roche A, Griffin E, Looby S, et al. Direct carotid puncture for endovascular thrombectomy in acute ischemic stroke. J NeuroIntervent Surg. 2019;11(7):647-652, ©The Authors, 2019, with permission from Dr Sarah Power. Table at 6:22 reproduced from Jadkhav AP, Ribo M, Grandhi R, et al. Transcervical access in acute ischemic stroke. J NeuroIntervent Surg. 2014:6(9):652-657, ©2013, with permission from the BMJ Publishing Group Ltd.