Endovascular carotid artery revascularization utilizing multiple distal embolic protection strategies: active and passive flow reversal in combination with balloon assisted reperfusion.

BACKGROUND

Carotid artery stenosis is a common cause of stroke. Carotid artery stenting (CAS) includes multiple approaches to endovascular carotid revascularization, including transfemoral/transradial CAS (TF-CAS/TR-CAS) and transcarotid artery revascularization (TCAR). Although CAS has declined in frequency since the development of TCAR, distal embolic protection (DEP) strategies differ between the two procedures, with studies reporting a lower risk of stroke with TCAR. TCAR uses open surgical common carotid artery clamping combined with passive flow reversal (PFR), whereas traditional TF-CAS/TR-CAS often employs a DEP device. Modifications to TF-CAS/TR-CAS include balloon guide catheter (BGC) carotid occlusion and PFR for additional DEP, mirroring aspects of TCAR.

METHODS

Patients underwent endovascular carotid artery revascularization (ECAR) using either transfemoral or transradial approaches (i.e., TF-CAS/TR-CAS) with the implementation of multiple DEP strategies: proximal flow arrest with a BGC, active flow reversal (AFR) and PFR, DEP device, and balloon-assisted reperfusion (BAR).

RESULTS

Two patients underwent successful TF-CAS/TR-CAS utilizing a DEP device in combination with novel adjuvant endovascular techniques. BGC occlusion of the common carotid artery provided anterograde flow arrest. AFR was employed during scenarios where PFR was not feasible or insufficient. BAR was performed with transient balloon occlusion of the proximal internal carotid artery during common carotid artery reperfusion and restoration of anterograde blood flow.

CONCLUSION

Adjuvant endovascular techniques can be employed during TF-CAS/TR-CAS that provide similar, if not more, DEP strategies to those used during TCAR. A purely endovascular approach lends itself to a multitude of specialists and eliminates wound care post-procedure, contributing to higher patient satisfaction and fewer complications.