Lateral Decubitus Transradial Carotid Artery Stenting in Ankylosing Spondylitis: A Novel Positioning Strategy

BACKGROUND Carotid artery stenting is conventionally performed with the patient in supine position. However, patients with ankylosing spondylitis and severe spinal rigidity are frequently unable to tolerate supine positioning due to fixed spinal deformity ("bamboo spine"). General anesthesia for surgical carotid endarterectomy carries additional risks in such patients owing to anticipated difficult airway management secondary to cervical spine ankylosis and fixed flexion deformity. These anatomical and anesthetic constraints necessitate alternative procedural approaches. CASE REPORT A 70-year-old man with a 40-year history of ankylosing spondylitis presented with recurrent cerebral infarction manifesting as right-sided limb weakness and slurred speech. Computed tomography angiography (CTA) demonstrated 80% stenosis of the right internal carotid artery. Unable to tolerate supine positioning beyond 2 min due to complete spinal rigidity, the patient underwent transradial carotid artery stenting in the right lateral decubitus position under local anesthesia without sedation, enabling continuous neurological monitoring. Positioned at a 45° lateral tilt with cylindrical towel roll support, C-arm angulation (LAO 15°/Cranial 3°) was optimized for adequate fluoroscopic visualization. An XACT stent (6-8-40 mm; Abbott Vascular) was deployed under distal embolic protection for 32 min with no complications. The patient was discharged on postoperative day 3 with complete symptom resolution. Three-month follow-up CTA confirmed stent patency without restenosis. CONCLUSIONS Lateral decubitus positioning combined with transradial access and local anesthesia is a safe and feasible alternative for carotid artery stenting in ankylosing spondylitis patients who cannot tolerate conventional supine positioning.