Carotid Artery Stenting Technique

Updated: Apr 08, 2016
  • Author: Faisal Aziz, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Technique

Approach Considerations

Access for carotid artery stenting (CAS) can be obtained through a variety of approaches, as follows:

  • Femoral - This is the approach preferred by most interventionalists; it avoids technique-related angulation and offers improved guide-wire and catheter maneuverability
  • Brachial/radial - A brachial approach is associated with a risk of damaging the median nerve; moreover, owing to the extreme angulation, manipulation of the catheter is difficult with this approach
  • Carotid - Both percutaneous and direct open exposures have been reported, and both are associated with the risk of causing inadvertent dissection and inadvertent crossing of the stenotic lesion; these approaches have largely been abandoned
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Carotid Stent Insertion

The standard technique for CAS is described below. Certain steps may vary, depending on the patient’s anatomy and the surgeon's preferences (see the image below).

Key steps in carotid stenting. Image courtesy of K Key steps in carotid stenting. Image courtesy of Kurt Mansor, Jobst Vascular Institute.

The patient is placed in a supine position. Both femoral regions are prepared and draped in a standard fashion. Anatomic landmarks are marked on the patient (ie, the anterior superior iliac spine and pubic tubercle).

The femoral pulsation is palpated, and a micropuncture needle is inserted one fingerbreadth below the inguinal ligament. Upon entry into the artery, a hydrophilic wire is inserted through the needle by means of the Seldinger technique. The needle is removed and is replaced by a 4-French sheath. The sheath is upsized to 6 French.

A guide wire is advanced into the aorta under direct fluoroscopy. An H1 catheter is placed over the guide wire and positioned in the aortic arch. Heparin 80 IU/kg is administered. An aortogram is obtained in the left anterior oblique position at 45° of angulation. The aortic arch, innominate artery, left common carotid artery, and left subclavian artery are identified. Selective catheterization of the left or right common artery is performed.

The guide wire is placed in the external carotid artery, and the H1 catheter is then placed in the external carotid artery. The guide wire is replaced with a stiffer wire (Amplatz/Lunderquist wire). A shuttle sheath is advanced to the common carotid artery. A carotid arteriogram is obtained (in anteroposterior, lateral, and intracerebral views).

The lesion is crossed with 0.014-in. wire. A cerebral protection device (CPD) is positioned with a monorail system. Predilatation is performed with a 2- to 3-mm balloon. The stent is placed across the lesion and deployed.

A repeat arteriogram is performed (see the image below). Any residual stenosis exceeding 30% is treated with balloon angioplasty. Sheaths and wires are removed, and an access site closure device is deployed.

Images show vessel before and after carotid artery Images show vessel before and after carotid artery stenting. Image courtesy of Cheong Lee, MD.
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Complications

Long-term outcomes of CAS remain to be fully defined. One study reviewed records for 219 patients who underwent CAS between August 2000 and March 2009 to assess the risk of carotid stent fractures or deformations following the procedure. Results showed a 15% rate of fracture or deformation at 2 years and a 50% rate at 4 years. Open-cell stents led to deformation more frequently than closed-cell stents did, and stent fractures were significantly associated with heavy calcification. These are potentially important early observations which need to be recorded for all CAS patients to determine future clinical implications. [13]

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