Turn-Over Technique for Inserting and Stabilizing Guiding Sheath without Straightening It during Carotid Artery Stenting via Trans-Brachial Approach in Cases with Severe Vascular Access Conditions

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Objective: In cases of severe atherosclerosis or tortuous arteries, inserting the guiding sheath into the target vessel is challenging. Here, we present the turn-over technique for inserting and stabilizing the guiding sheath without straightening it during carotid artery stenting (CAS).

Case Presentation: Two patients with severe left internal carotid artery stenosis underwent CAS via the trans-brachial approach. Although inserting the guiding sheath into the common carotid artery using conventional techniques was challenging, we succeeded in inserting it into the target vessel using the “turn-over technique.” At first, the guidewire was U-turned just above the aortic valve and inserted into the left external carotid artery. The inner catheter and guiding sheath were then followed along the guidewire to the left common carotid artery, and the guidewire and inner catheter were removed. The guiding sheath was stable in a U-turned position, and straightening the guiding sheath was difficult. Devices such as stents and balloons could be delivered without problems, and CAS was completed with the guiding sheath in a U-turned position.

Conclusion: The turn-over technique for inserting and stabilizing the guiding sheath for CAS via the trans-brachial approach is an option in cases of difficult catheter access due to atherosclerosis or tortuous arteries.