Elsevier

World Neurosurgery

Volume 113, May 2018, Pages 257-260
World Neurosurgery

Technical Note
Balloon Bridge: Novel Technique for Reaccessing Carotid Artery Stent

https://doi.org/10.1016/j.wneu.2018.02.091Get rights and content

Highlights

  • Carotid artery stent placement may require reentry with a balloon or catheter.

  • Complications can occur if a traversing catheter gets caught on the stent.

  • The risk of stent snag increases by a steep carotid artery angle of origin.

  • The novel “balloon bridge” technique allows a catheter to safely cross the carotid stent.

Background

Crossing a nascently deployed carotid artery stent (CAS) is required to perform angioplasty and filter recapture. If the traversing balloon or filter recapture catheters are eccentric or tangentially angled to the vertical axis of the CAS, they can ensnare on the ledge of the proximal CAS step-off, potentially causing life-threatening complications secondary to deformation, displacement, or mechanical occlusion of the stent. We report a novel “balloon bridge” technique that facilitates safe entry and passage across the CAS with both a balloon catheter and a large-bore guide catheter (LBGC).

Methods

We used the balloon bridge technique for 2 patients with >90% carotid artery stenosis and steep carotid artery angles of origin who underwent routine CAS, balloon angioplasty, and distal embolic protection. During filter recapture, the balloon was inflated across the junction of the distal LBGC tip and proximal CAS, centering the LBGC within the vessel lumen and CAS. During balloon deflation, the LBGC was sequentially advanced, successfully navigating the LBGC across the proximal stent construct without resistance or complication.

Results

The balloon bridge technique was completed without complications. We believe that the mechanism of action is secondary to balloon-facilitated LBGC alignment with the true axis of the stent.

Conclusions

Traversing a CAS with an LBGC or balloon catheter can be tedious and fraught with the potential of neurologic peril should mechanical deformation and occlusion occur. The balloon bridge technique is safe and highly effective for navigating a catheter that is eccentric or tangentially angled to the long axis of a CAS.

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)

  • J.B. Martin et al.

    Role of the distal balloon protection technique in the prevention of cerebral embolic events during carotid stent placement

    Stroke

    (2001)
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