Technical NoteBalloon Bridge: Novel Technique for Reaccessing Carotid Artery Stent
Introduction
Placement of a carotid artery stent (CAS) frequently requires reentry and crossing with an angioplasty balloon and a filter recapture catheter. When the aforementioned catheters will not track over the filter wire, the proximal large-bore guide catheter (LBGC) can be advanced into the CAS in order to deliver smaller catheters. Introduction of the LBGC into the CAS can also serve as a “bail-out” for recapturing an overloaded distal embolic protection device.1 In addition, CAS reaccess is also frequently indicated during mechanical thrombectomy for large-vessel intracranial occlusions.
Anatomically, a challenge arises when the carotid artery angle of origin is steep.2 Structurally, this creates a proximal ledge between the interface of the arterial lumen and the stent, forcing the catheter system to rest tangentially and eccentric to the lumen. Life-threatening complications can occur if stent reaccess with the balloon prevents angioplasty or the LBGC ensnares and subsequently deforms the CAS.3 We believe the following technique is useful for advancing both balloon catheters and LBGCs across a CAS.
Section snippets
Technique
We demonstrate the application of the “balloon bridge” technique for entering and crossing a CAS that presents a step-off at the proximal origin. This technique is useful in 2 situations, the first occurring at the time of angioplasty. If the balloon cannot be introduced across the proximal CAS ledge, it is positioned just outside the CAS, partially inflated to 30%−50% capacity, and concurrently advanced (Figure 1A–C, Video 1).
The second situation where the balloon bridge can be employed occurs
Case 1
A 77-year-old man presented with asymptomatic left internal carotid artery (ICA) stenosis previously identified on magnetic resonance angiography. Pretreatment angiography demonstrated left ICA stenosis >90%. The modified Seldinger technique was used to introduce a 6-Fr Shuttle guide catheter (Cook, Bloomington, Indiana, USA) over an Amplatz guidewire into the right femoral artery and advanced into the descending thoracic aorta under direct fluoroscopic visualization. A 5-Fr VTK catheter and a
Discussion
We believe that the mechanism of action is secondary to the balloon's ability to act as an inflatable recentering device that facilitates catheter system alignment with the true axis of the stent. Since the development of this technique, it has been repeatedly used at our institution without complication.
Conclusions
Traversing a CAS with an LBGC can be exceedingly tedious and fraught with the potential of neurologic peril should mechanical deformation and occlusion occur. The balloon bridge technique is a safe and highly effective method for navigating a catheter that is eccentric or tangentially angled to the long axis of a CAS.
References (3)
- et al.
Role of the distal balloon protection technique in the prevention of cerebral embolic events during carotid stent placement
Stroke
(2001)
Cited by (0)
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