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Published on: May 9, 2013
Staged strategy using a transcarotid approach for acute tandem occlusions with left common carotid artery origin
Ryosuke Maeoka1,2, Ichiro Nakagawa2, Hiroyuki Ohnishi1
1Department of Neurosurgery, Ohnishi Neurological Centre, Akashi, Hyogo, Japan.
Insights
A staged approach for acute tandem occlusions involving the left common carotid artery (LCCA) origin and intracranial arteries is effective. This method, using retrograde transcarotid stenting, offers a safer alternative to simultaneous treatment for complex cases.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Radiology
Background:
- Acute tandem occlusion (ATO) presents challenges, particularly when involving extracranial internal carotid artery (ICA) steno-occlusive lesions alongside intracranial occlusions.
- The optimal timing for treating extracranial lesions, specifically at the left common carotid artery (LCCA) origin, in conjunction with intracranial interventions remains unclear.
Observation:
- Two patients with ATO involving LCCA origin steno-occlusive lesions underwent emergent mechanical thrombectomy for intracranial recanalization.
- Severe LCCA stenosis persisted post-thrombectomy. Due to a tortuous aortic arch, a staged endovascular approach was chosen.
- Successful LCCA stenting was performed via a retrograde transcarotid approach through common carotid artery (CCA) cutdown in a separate session.
Findings:
- The staged strategy, addressing LCCA origin stenosis after intracranial recanalization, proved successful in both cases.
- The retrograde transcarotid approach for LCCA stenting was technically feasible and complication-free.
- Patient outcomes were favorable with symptom improvement post-intervention.
Implications:
- A staged endovascular treatment strategy appears superior to simultaneous intervention for ATO with LCCA origin steno-occlusive lesions.
- The retrograde transcarotid approach via CCA cutdown is a recommended technique for LCCA stenting in these complex scenarios.
- This approach may improve outcomes for patients with challenging tandem occlusions requiring multi-level intervention.
Background:
Endovascular treatment for acute tandem occlusion (ATO) of the combination of an ipsilateral extracranial internal carotid artery (ICA) steno-occlusive lesion with concurrent intracranial artery occlusion is challenging. Whether extracranial lesions, especially in cases of the left common carotid artery (LCCA) origin steno-occlusive lesions, should be treated after recanalization of an occluded intracranial artery by mechanical thrombectomy simultaneously in the same session has not been established. We report two cases of successful ATO with LCCA origin steno-occlusive lesions treated by staged retrograde transcarotid LCCA stenting followed emergent mechanical thrombectomy in two sessions because of the tortuous aortic arch.
Case Description:
A 61-year-old man with left ICA occlusion and an 82-year-old woman with left middle cerebral artery occlusion underwent emergent mechanical thrombectomy for ATO with LCCA origin stenoocclusive lesions. We achieved recanalization of large vessels, but severe stenosis of LCCAs remained. Because of the tortuous aortic arch, we decided to treat LCCA origin steno-occlusive lesions with staged stenting in the other session followed emergent mechanical thrombectomy. Postoperative courses were uneventful, and their symptoms improved. We performed stenting using a transcarotid approach through CCA cut down for LCCA steno-occlusive lesions without any complications.
Conclusion:
The staged strategy leaving LCCA origin stenosis seems to offer a better strategy than the simultaneous strategy for ATO with LCCA origin steno-occlusive lesions. A retrograde transcarotid approach through CCA cut down is recommended for LCCA stenting.
