Introduction: Direct cervical carotid exposure for endovascular access provides of means of bypassing difficult anatomy of the aortic arch or proximal brachiocephalic vessels in those patients with cerebrovascular anomalies most amenable to endovascular therapy, while additionally providing the security of a direct visualization of the arteriotomy closure in the setting of a mandatory antiplatelet regimen.
Methods: Here we present an 82-year-old female with regrowth of a right posterior communicating artery aneurysm that had been previously treated with coil embolization. Due to significant tortuosity of her proximal vasculature, direct carotid exposure was utilized for access for coil and Pipeline embolization. The patient was continued on her daily dual antiplatelet regimen pre-operatively. In the operating room and under general endotracheal anesthesia, the right carotid sheath was exposed and opened, vessel loops placed around the common and internal carotid arteries, and the incision was then closed. In the angiography suite, the incision was re-opened and the right internal carotid artery was accessed with direct microstick, using Seldinger technique, and exchanged for a 5 French short groin sheath. After a standard diagnostic angiogram and coil embolization with bare platinum coils, a Pipeline embolization device was deployed through a Navien support catheter and a Marskman microcatheter. After all catheters and the sheath were removed, the ICA was closed with 6-0 Prolene sutures and the incision closed in the usual fashion.
Results: The patient tolerated the procedure well and was discharged on post-operative day 1. She was continued on her dual antiplatelet regimen. At her thirty-day follow up, the patient remained at her neurological baseline and was doing well.
Conclusions: Surgical exposure of the cervical carotid artery may be safely utilized as a means of providing vascular access for deployment of Pipeline embolization device in patients for whom the standard transfemoral approach is not feasible.
Patient Care: This case report is the first known description of the utilization of direct carotid exposure for placement of a Pipeline device. A technical description of a successfully-performed procedure may allow other surgeons and interventionalists to offer an alternative therapy for patients with similar conditions.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Understand the indications for direct carotid access for endovascular therapies
2) Discuss the merits of direct versus percutaneous carotid access
3) Describe the technique of carotid artery exposure for subsequent endovascular access