2025 Volume 19 Issue 1 Article ID: cr.2025-0085
Objective: We report a unique case of carotid artery stenting (CAS) conducted via direct puncture of an aortic arch graft in a patient who underwent total arch replacement (TAR), complicated by carotid artery dissection.
Case Presentation: A 72-year-old woman underwent TAR for an ascending aortic aneurysm. Aortic dissection extending to the right carotid artery was detected immediately after the aortic arch graft anastomosis, which resulted in severe stenosis and decreased cerebral perfusion. Therefore, urgent revascularization was deemed necessary. The aortic arch graft was directly punctured, followed by the placement of 3 stents to seal the dissection. Postoperative imaging confirmed the restoration of blood flow without ischemic complications. The patient, who recovered without neurological deficits or cardiosurgical complications, has remained event-free for 3 years after the intervention.
Conclusion: Direct puncture of the aortic arch graft provides a reliable and rapid access route for CAS in patients undergoing carotid artery dissection following TAR. This method may serve as an alternative when conventional access is difficult. Antithrombotic therapy should be strictly controlled to avoid procedure-related complications.
Total arch replacement (TAR) is a complex surgical procedure used to treat aortic arch aneurysms and dissections. Secondary vessel dissection is a serious complication of TAR,1,2) and cerebral malperfusion can occur if the dissection extends to the carotid arteries, requiring urgent medical intervention. Carotid artery stenting (CAS) is a possible intervention in such cases; however, the access route may be difficult. Herein, we report a case of CAS performed by direct puncture of an aortic arch graft during TAR complicated by carotid artery dissection.
A 72-year-old woman with a past medical history of hypertension and hyperlipidemia was referred to our institution due to a stomachache. 3D CTA of the chest revealed an incidental ascending aortic aneurysm with a diameter of 6 cm (Fig. 1A). Routine MRA of the cerebral arteries revealed a persistent primitive hypoglossal artery originating from the right internal carotid artery (Fig. 1B). According to the patient’s preference, a cardiovascular surgeon conducted a TAR through median sternotomy and total body retrograde perfusion with hypothermic circulatory arrest. Intraoperative heparinization was required, and activated clotting time (ACT) was monitored, maintaining a target of approximately 250. Regional cerebral oxygen saturation was monitored bi-frontally using the INVOS 5100C (Medtronic Japan, Tokyo, Japan). The primary branches were replaced with a 4-branched J-graft (Japan Lifeline, Tokyo, Japan) with selective cerebral perfusion.
After the aortic arch was replaced with the J-graft, cerebral and systemic circulation was restored, and the patient was gradually rewarmed; however, the right INVOS monitoring level decreased. Transesophageal echocardiography revealed a wide false lumen in the innominate artery, and a newly developed aortic dissection was suspected (Fig. 2A). Carotid Doppler ultrasonography showed that the dissection had extended to the right common carotid artery with severe stenosis (Fig. 2B). Immediately, reanastomosis of the innominate artery was performed by the cardiovascular surgeon; however, no improvement of the dissection was observed, and the INVOS monitoring level continued to decrease. Urgent therapeutic interventions for revascularization were considered. An accurate capture of the true lumen was required; therefore, we planned an approach using the replaced arch graft. After initiating dual antiplatelet therapy (aspirin 200 mg and clopidogrel 300 mg), we performed a direct puncture at the 1st branch of the replaced J-graft with an 18-gauge needle at a site proximal to the anastomosis. Using C-arm fluoroscopy, we gently directed a 0.035-inch guidewire, and the 8-Fr 10-cm sheath (Terumo, Tokyo, Japan) was inserted using the Seldinger method (Fig. 3). To prevent the sheath from being dislodged, the assistant continuously held it throughout the endovascular procedure. The ACT was monitored, maintaining a target of 250–300 during the endovascular procedure. Initial angiography revealed a dissection involving an area from the innominate artery to the carotid artery bifurcation, with the wide false lumen compressing the true lumen, leading to reduced anterograde cerebral flow (Fig. 4A). The dissection site was determined based on the transesophageal echocardiography, carotid Doppler ultrasonography, and initial cerebral angiography (Fig. 4B). An 8-Fr Slimguide (Medikit, Tokyo, Japan) guiding catheter was placed proximally to the right common carotid artery orifice. Using a CHIKAI 14 (Asahi Intecc, Aichi, Japan) microwire and Trevo Trak 21 (Stryker Neurovascular, Fremont, CA, USA) microcatheter, we carefully navigated across the dissection. After advancing the catheter to the distal site, angiography confirmed that it was positioned in the true lumen (Fig. 5A). A 10 × 40 mm Precise Pro RX (Cordis, Miami Lakes, FL, USA) was deployed from the common carotid artery to cover the false lumen, where the stenosis appeared to be most severe. Blood flow into the false lumen had decreased, but the anterograde cerebral flow was still delayed. Therefore, 2 stents (10 × 31 mm Carotid Wallstent [Boston Scientific, Marlborough, MA, USA] and 10 × 40 mm Precise Pro RX) were proximally overlapped over the 1st stent (Fig. 5B). Vessel narrowing markedly decreased, and anterograde cerebral blood flow with no delay was confirmed (Fig. 5C and 5D). Post-treatment, carotid Doppler ultrasonography showed that the flow of the true lumen was dilated (Fig. 6A), and the right INVOS monitoring level had increased. The puncture sites were closed directly using Prolene sutures (Johnson & Johnson, Somerville, NJ, USA). The ACT at the end of the procedure was 220. The time from sheath insertion to final angiography was 68 minutes. The patient recovered without postoperative neurological deficits or cardiosurgical complications. MRI performed 1 day after the procedure revealed no ischemic lesions. Post-procedural CTA demonstrated 3 overlapping stents placed from just proximal to the carotid bifurcation to the distal part of the graft anastomosis. No in-stent stenosis or migration was observed, and the true lumen was sufficiently expanded (Fig. 6B). Dual antiplatelet therapy with aspirin 100 mg and clopidogrel 75 mg was continued on the day following the procedure. Aspirin was discontinued after 3 months, and clopidogrel monotherapy was maintained thereafter. No adverse events were observed for 3 years following the intervention. Follow-up CTA showed no findings of stent restenosis or migration.
Carotid artery dissection after aortic replacement surgery is an important complication that can occur as a result of a mechanical tear or secondary to dehiscence at the anastomosis site. According to Zieliński et al., vascular dissections at the anastomotic site develop in approximately 15% of patients after TAR. Most of these dissections are asymptomatic and can be managed conservatively; however, symptomatic dissections are rare, occurring in only 0.7% of all patients undergoing TAR.3) If progressive neurological symptoms or a considerable decrease in cerebral blood flow are indicated, urgent therapeutic intervention may be necessary. CAS has shown efficacy in symptomatic carotid artery dissection related to aortic dissection and is typically performed using a transfemoral or transbrachial/radial approach.4) Direct carotid puncture can be an option in cases where conventional access routes become technically challenging, such as cervical vascular tortuosity or a rerouted aorta due to aortic replacement.5) If the dissection is extended to wide lesions in the carotid artery, selective catheterization of the true lumen of the carotid artery may be challenging. In our case, the standard transfemoral approach was deemed difficult due to the following reasons: 1) urgent revascularization was needed because of the involvement of the posterior circulation through the persistent primitive hypoglossal artery; 2) the dissection occurred in the cardiovascular operating room with median sternotomy; thus, preparing the brachial or groin puncture site was potentially overly time-consuming; 3) precise sheath insertion and catheter access were necessary. Furthermore, as the distal extent of the dissection was unclear, retrograde direct carotid puncture was considered challenging, and we elected to puncture the replaced aortic arch graft.
We summarized recent case reports about direct puncture of an aortic arch graft (Table 1).6,7) In 2 cases, the treatment was performed during aortic graft replacement for type A acute aortic dissection. In the present case, the dissection occurred during TAR for an aortic aneurysm. In all cases, the endovascular treatment was performed with a sheath size greater than 6 Fr, and several carotid stents were required to cover the extended dissection. Although the aorta was replaced, CAS was successfully performed in all cases without any complications or major neurological deficits. The main advantage of direct puncture of the aortic arch graft is that the procedure is performed in a wide and clear field, allowing for a rapid and precise puncture for the access route. Direct puncture of the exposed carotid artery and aortic arch graft was conducted under direct vision, contributing to reliable and rapid vascular access and ensuring true lumen catheterization.8) Furthermore, direct puncture of the aortic arch graft also provides safe hemostasis of the puncture site. As mentioned in previous reports, a large sheath size is required in CAS treatment for TAR-associated carotid dissection, making puncture site hemostasis an important consideration. Performing CAS by percutaneous puncture could pose challenges in achieving hemostasis upon sheath removal.5) In carotid percutaneous puncture, manual compression of the carotid artery could trigger reduced intracranial blood flow, insufficient compression-related hematoma formation, and respiratory distress due to neck swelling.9) In addition, because CAS is often performed under multiple antithrombotic agents, the risk of bleeding is relatively high.10) Direct puncture CAS performed on an exposed aortic graft reportedly represents a low risk of post-closure bleeding and hematoma formation at the puncture site.6) Direct suturing of the puncture point under direct vision could be performed safely and precisely to prevent wound bleeding, as demonstrated in this case study.
| Author (year) | Age (years), sex | Cardiovascular disease | Replacement strategy | Occlusion site | Sheath size (Fr) | Endovascular treatment strategy | Antithrombotic therapy | Complication | 3-month mRS |
|---|---|---|---|---|---|---|---|---|---|
| Chen et al. (2022)6) | 60, Male | Type A aortic dissection | Ascending arch replacement | Rt. CCA–proximal ICA | 6 | CAS (Carotid Wallstent ×2) | Tirofiban | No | 1 |
| Tsai and Shen (2014)7) | 54, Male | Type A aortic dissection | Total arch replacement | Lt. CCA | 12 | CAS (Viabahn) | Not mentioned | No | 0 |
| Current case | 72, Female | Ascending aortic aneurysm | Total arch replacement | Innominate A–Rt. CCA | 8 | CAS (Carotid Wallstent ×2, Precise Pro RX) | Heparin, DAPT (ASA + CLO) | No | 0 |
ASA, aspirin; Carotid Wallstent, Boston Scientific, Marlborough, MA, USA; CAS, carotid artery stenting; CCA, common carotid artery; CLO, clopidogrel; DAPT, dual antiplatelet therapy; ICA, internal carotid artery; Lt., left; mRS, modified Rankin Scale; Precise Pro RX, Cordis, Miami Lakes, FL, USA; Rt., right; Viabahn, W. L. Gore & Associates, Flagstaff, AZ, USA
Consensus has not yet been established regarding the appropriate strategy for antithrombotic therapy in aortic dissection-related direct puncture CAS. In conventional CAS, dual antiplatelet therapy initiation prior to the procedure and intraoperative heparin administration are common.11) However, in aortic dissection-associated carotid artery dissection, often requiring multiple stent placements, greater caution must be taken concerning the risk of stent thrombosis.12) Kawanami et al. described the safe and effective use of dual antiplatelet therapy in carotid artery dissection emergency CAS.4) Insufficient antithrombotic therapy after CAS poses a risk of in-stent thrombosis.10) In contrast, excessive antithrombotic drugs may increase the risk of hemorrhagic complications, representing a particular concern in the direct puncture of an aortic graft when endovascular treatment is performed immediately after open cardiac surgery.13) Therefore, bleeding from an anastomosis or the surgical site, such as the sternum or pericardium, should be carefully considered.14) In the hereby-presented case, heparinization was strictly monitored during endovascular treatment, without any complications. Nevertheless, further studies are warranted on appropriate antithrombotic therapy use in CAS by direct puncture of a replaced aortic graft.
We report a case of CAS by direct puncture of an aortic arch graft during TAR, which resulted in a favorable outcome. This method may be an optional treatment for carotid dissections related to TAR. Careful control of antithrombotic therapy is necessary to reduce procedure-related complications.
The authors declare that they have no conflicts of interest.
