Transfemoral stenting of stenosis at the common carotid artery (CCA) is a relatively uncommon procedure compared with that for a stenotic lesion of the cervical internal carotid artery (ICA). It may be technically difficult to advance and stabilize the guiding catheter during the procedure. It is particularly difficult in the left common carotid artery (LCCA) because of its anatomical features. However, the degree of difficulty differs depending on the distance from the orifice to the stenotic lesion and the angle of the LCCA and aortic arch. Here, we report guiding catheter techniques for revascularization of LCCA stenosis.
We choose an appropriate method based on the degree of difficulty. When there is enough distance between the LCCA orifice and the stenotic lesion, and the LCCA does not branch at an acute angle, advancement of the guiding catheter may be possible using a routine method. However, if the LCCA branches at an acute angle, it might be necessary to pass through the lesion using a guidewire or an inner catheter before advancing the guiding catheter. First, a guiding catheter is placed at the LCCA orifice using a triple coaxial system, and a 300-cm GuardWire (Medtronic, Minneapolis, MN, USA) is placed at the ICA. Once the 4-Fr inner catheter is removed under distal balloon protection, a 0.035-inch guidewire is inserted into the external carotid artery and the guiding catheter can be easily and safely placed at the optimal position. When the stenotic lesion is at the LCCA orifice, a pull-through technique is performed using a 300-cm 0.014-inch guidewire between the superficial temporal artery and femoral artery. A 0.035-inch-compatible, balloon-expandable stent system is also introduced over the 0.014-inch guidewire, with a GuardWire placed at the ICA.
Several endovascular techniques have been described for revascularization to treat LCCA stenosis. In general, a more invasive method is required for complete protection and stabilization of the guiding catheter. Selection of an appropriate method to treat LCCA stenosis based on the degree of difficulty is mandatory to ensure feasibility and safety.