Excessive tortuosity is a notable cause of failed endovascular thrombectomy for acute large-vessel occlusion stroke. Transcervical access (TCA) is a commonly proposed solution for overcoming this difficulty. However, the large-bore catheter usually used in TCA increases the risk of serious local complications. This paper presents a modified technique for TCA that uses a pull-through buddy wire (PTBW) to track a large-bore femoral guiding sheath (GS) into the carotid artery via a small carotid puncture site. The carotid puncture site can be easily managed through gentle manual compression. Two illustrative cases using this technique to deal with a large aortic arch and tortuous left common carotid artery are reported. In both cases, recanalization was achieved after successful GS placement. Using a PTBW is feasible in TCA.
Endovascular thrombectomy (EVT) is a standard treatment for acute large-vessel occlusion (LVO) stroke [
In this paper, we present a modified TCA using a pull-through buddy wire technique (PBWT) for anterior circulation LVO stroke. Two illustrative cases are reported.
Under local anesthesia, an 8-Fr Flexor Shuttle guiding sheath (GS) (COOK Medical, Bloomington, IN, USA) is first inserted into the proximal descending aorta through the transfemoral approach. Under ultrasonographic guidance, a 20-G venous catheter is retrogradely punctured into the distal common carotid artery (CCA), followed by insertion of a 0.014-inch microwire. A snare catheter is inserted into the aortic arch through the femoral GS. The microwire is then captured by the snare catheter (
An 87-year-old female with a medical history of hypertension and dyslipidemia presented to our emergency department with severe dysarthria, slurred speech, and right hemiplegia for 1.5 hours. A National Institutes of Health Stroke Scale (NIHSS) score of 18 was reported. Computed tomography angiography (CTA) revealed the middle cerebral artery (MCA) occlusion at the M1 segment. The patient was transferred to a neuroangiography suite for endovascular treatment.
Excessive tortuosity of the aorta was reviewed using CTA before the procedure was performed (
An 80-year-old male with a medical history of hypertension and hyperlipidemia had previously had a left ethmoidal dural arteriovenous fistula, which was causing intracerebral hemorrhage. He had received craniectomy and stereotactic radiosurgery 10 years before the present case. During a follow-up magnetic resonance study, severe left M1 stenosis was found (
However, 40 minutes following femoral puncture, the GS could not be successfully inserted into a stable position in the CCA. The PBWT was applied after disinfection and preparation of the neck (
Two weeks after discharge, the patient’s symptoms were ameliorated and his NIHSS score was 6 with shuffling gait and aphasia. He received dual antiplatelet therapy. However, in-stent occlusion was noted 3 months later after an episode of acute stroke. No further endovascular treatment was performed. His mRS score was 3 at 3 months after recurrent stroke.
TCA is a commonly mentioned alternative for difficult EVT, and special care should be taken to avoid large arterial puncture wounds. In this report, the PBWT, a modified TCA technique, was demonstrated. Its advantage is its ability to minimize potential vascular trauma to the CCA while maintaining stable support of the GS.
TCA has been adapted in many neuroendovascular treatments, including arteriovenous malformation embolization, aneurysm coiling, and carotid artery stenting [
The pull-through technique was first reported in 1988 for occluded iliac artery treatment [
The most notable advantage of the PBWT is that it reduces the puncture wound size in the CCA. In our experience, manual compression for 10 minutes is sufficient for achieving hemostasis. The second advantage is that the locked microwire can stabilize the GS during the following procedure. However, there are some potential drawbacks to bear in mind. First, the reperfusion catheter is contained in the GS parallel to the microwire; therefore, a larger GS should be used. We used an 8-Fr GS instead of the more common 6-Fr GS. Second, the tip location of the GS was limited by the puncture site at the distal CCA. Although the system was stable, the low position of the GS could not further reduce redundancy of the internal carotid artery. Third, snaring the microwire in the aortic arch is not always easy and may require additional time if operators are unfamiliar with the technique.
The PBWT might be feasible for modified TCA that can be applied in EVT to overcome excessive tortuosity. It can have the potential benefit of decreased risk of cervical puncture site complications.
None.
The study was approved by the research ethics committee of the National Taiwan University Hospital.
The authors have no conflicts to disclose.
Concept and design: CWL. Analysis and interpretation: YHL and YCH. Data collection: PYC and YCH. Writing the article: PYC. Critical revision of the article: YHL. Statistical analysis: PYC and YCH. Overall responsibility: CWL.
Illustration of the pull-through technique in the CCA. (
Application of the pull-through technique during EVT for left MCA M1 occlusion. (
Switch to the pull-through technique during stenting for acute occlusion of the left MCA M1 with underlying severe stenosis. (