Transcarotid artery revascularization in reverse for innominate artery stenosis

Stenotic lesions of the supra-aortic vessels have been reported in 2-6% of patients presenting with corresponding symptoms. In the past, these lesions have been treated with open surgical techniques. More recently, endovascular treatment approaches have been proposed for occlusive lesions in the innominate (IA) or common carotid (CCA) arteries. Retrograde stenting of IA and CCA lesions using flow reversal has been described in a retrospective case series; however, a modification of their technique is proposed. Case Presentation: The patient is a 68-year-old male with symptoms of right upper extremity claudication. CT angiogram revealed critical stenosis of the innominate artery and high-grade stenosis of the right subclavian artery. The patient consented to retrograde stenting of the innominate stenosis with neuroprotection using flow reversal or transcarotid revascularization (TCAR) in reverse. Surgical cut-down was performed of the carotid bifurcation, and a U-stitch was placed on the anterior wall of the distal common carotid artery. Flow reversal was achieved by connecting the arterial sheath to the venous sheath. The innominate lesion was crossed, primarily stented with a VBX stent, and post-dilated with a non-compliant balloon. Just prior to crossing the lesion and primary stent placement, the vessel loop around the common carotid and internal carotid arteries were pulled up to ensure neuroprotection while the stent was expanded. This was continued for two minutes before restoring antegrade flow first in the external carotid and then in the internal carotid artery. There were no adverse events. At one month follow-up, the patient reported no right arm claudication symptoms. TCAR for the proximal lesion as described in other case series may not adequately attain flow based neuroprotection. Under that circumstance, the arterial sheath is acting as a conduit to deliver the stent. Risk of embolization to the brain may not be mitigated when the proximal lesion is stented and antegrade flow restored.