Transradial Carotid Artery Stenting
Transradial Carotid Artery Stenting
The use of noninvasive imaging (magnetic resonance angiography or computed tomographic angiography) should be individualized. Prior to the stent procedure, a complete evaluation of the aortic arch as well as bilateral carotid arteriography is required. In most patients with right internal carotid disease, a right anterior oblique angiogram of the innominate bifurcation should be evaluated. Initial angiography is performed through a 4- or 5-Fr diagnostic catheter. The specific curve of the diagnostic catheter is based on the type of arch and common carotid artery (CCA) take-off. Thus, different diagnostic catheters can be utilized for right ICA, bovine left ICA and nonbovine left ICA.
Most frequently, a reversed angle catheter, such as Simmons type 1 or 2, are primarily used for TRA carotid angiography (Terumo, Tokyo, Japan; Merit Medical, Galway, Ireland; Cordis Corporation, Warren NJ, USA). There are two methods of reforming the natural reversed curve of the Simmons catheters within the aortic arch. The first simply involves passing the catheter over a hydrophilic glidewire looped in the ascending aorta. This technique is used for a Simmons 1 or a Simmons 2 catheter in patients with a very tortuous and dilated aortic arch (Figure 3).
(Enlarge Image)
Figure 3.
Looping technique of a diagnostic Simmons 2 catheter over the hydrophilic wire in the ascendent aorta.
The second method is preferred for the Simmons 2 catheter in most cases. The catheter is negotiated into the descending thoracic aorta over a standard guidewire. The curve is reformed by withdrawing the guidewire into the primary curve and prolapsing the catheter into the ascending aorta with counterclockwise rotation. Sometimes, patient should take and hold a deep breath in order to facilitate catheter reformation in the ascending aorta.
With this maneuver the catheter forms a loop on itself, which often directly engages the left carotid. After angiography of the left carotid, catheter should be pushed, rotated and can be withdrawn into the right common carotid (Figures 4 & 5). The Simmons 2 catheter should be used with caution in the right common carotid of women and short patients as the distal limb may reach the bifurcation. Catheters with soft reversed angle tip are the most easily reformable and the least traumatic during diagnostic carotid angiography (Merit Medical, Galway, Ireland).
(Enlarge Image)
Figure 4.
Simmons 2 catheter in left common carotid artery for diagnostic angiography.
(Enlarge Image)
Figure 5.
Simmons 2 catheter in right common carotid artery for diagnostic angiography.
Transradial Carotid Angiography
The use of noninvasive imaging (magnetic resonance angiography or computed tomographic angiography) should be individualized. Prior to the stent procedure, a complete evaluation of the aortic arch as well as bilateral carotid arteriography is required. In most patients with right internal carotid disease, a right anterior oblique angiogram of the innominate bifurcation should be evaluated. Initial angiography is performed through a 4- or 5-Fr diagnostic catheter. The specific curve of the diagnostic catheter is based on the type of arch and common carotid artery (CCA) take-off. Thus, different diagnostic catheters can be utilized for right ICA, bovine left ICA and nonbovine left ICA.
Most frequently, a reversed angle catheter, such as Simmons type 1 or 2, are primarily used for TRA carotid angiography (Terumo, Tokyo, Japan; Merit Medical, Galway, Ireland; Cordis Corporation, Warren NJ, USA). There are two methods of reforming the natural reversed curve of the Simmons catheters within the aortic arch. The first simply involves passing the catheter over a hydrophilic glidewire looped in the ascending aorta. This technique is used for a Simmons 1 or a Simmons 2 catheter in patients with a very tortuous and dilated aortic arch (Figure 3).
(Enlarge Image)
Figure 3.
Looping technique of a diagnostic Simmons 2 catheter over the hydrophilic wire in the ascendent aorta.
The second method is preferred for the Simmons 2 catheter in most cases. The catheter is negotiated into the descending thoracic aorta over a standard guidewire. The curve is reformed by withdrawing the guidewire into the primary curve and prolapsing the catheter into the ascending aorta with counterclockwise rotation. Sometimes, patient should take and hold a deep breath in order to facilitate catheter reformation in the ascending aorta.
With this maneuver the catheter forms a loop on itself, which often directly engages the left carotid. After angiography of the left carotid, catheter should be pushed, rotated and can be withdrawn into the right common carotid (Figures 4 & 5). The Simmons 2 catheter should be used with caution in the right common carotid of women and short patients as the distal limb may reach the bifurcation. Catheters with soft reversed angle tip are the most easily reformable and the least traumatic during diagnostic carotid angiography (Merit Medical, Galway, Ireland).
(Enlarge Image)
Figure 4.
Simmons 2 catheter in left common carotid artery for diagnostic angiography.
(Enlarge Image)
Figure 5.
Simmons 2 catheter in right common carotid artery for diagnostic angiography.
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