Chapter 44: Upper Extremity and Carotid Artery Stenting

The femoral artery is the conventional access site for carotid stent procedures. However, this approach may be difficult or impossible in certain patients with anatomical variations of the aortic arch or common carotid artery and in patients with significant peripheral vascular disease. Previous feasibility studies and case reports have demonstrated that transradial access may be an alternative strategy in these patients.

Transradial insertion of a sheath for stent deployment is a variation of the technique used for femoral access. Thus, a diagnostic catheter positioned in the external carotid artery is used for insertion of an exchange length, supportive guide wire over which a guiding sheath or catheter is deployed. Once the guiding sheath is in place, the embolic protection device deployment and carotid stenting technique is precisely the same as from the femoral artery.

However, deployment of a guiding sheath from the right arm involves acute angles that must be negotiated, and different catheters and guide wires are required compared to those used for the femoral approach. The transradial technique for carotid stenting involves three different techniques for the three basic anatomical types of carotid disease: right internal carotid, non-bovine left internal carotid, and bovine left internal carotid (ICA).

Sasko Kedev, MD, PhD