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\begin{document}

\title{Carotid access for percutaneous coronary intervention}



\author[1]{Matthias De Boulle}%
\author[1]{Erik Debing}%
\author[1]{Dries Belsack}%
\author[1]{Bert  Vandeloo}%
\affil[1]{Universitair Ziekenhuis Brussel}%


\vspace{-1em}



  
  \date{May 28, 2024}


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\selectlanguage{english}
\begin{abstract}
Vascular access for percutaneous coronary intervention (PCI) is usually
obtained through the radial or femoral, and to lesser extent the
brachial or ulnar artery. We describe the transcarotid approach for PCI
in a patient with severe peripheral artery disease. No adverse
neurological or cardiac events were observed.%
\end{abstract}%



\sloppy


\emph{Title page}

\emph{Title:}

Carotid access for percutaneous coronary intervention

\emph{Authors:}

Matthias De Boulle, MD \textsuperscript{a}

Erik Debing, MD, PhD \textsuperscript{a}

Dries Belsack, MD \textsuperscript{b}

Bert Vandeloo, MD \textsuperscript{a}

\textsuperscript{a} Centrum voor Hart- en Vaatziekten, Vrije
Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ
Brussel), Brussels, Belgium

\textsuperscript{b} Department of Radiology, Vrije Universiteit Brussel
(VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium

\emph{Total word count} :

1355

\emph{Funding:}

None

\emph{Disclosure:}

All authors have reported that they have no financial disclosure
relevant to the content of this paper.

\emph{Address for correspondence} :

Name: Matthias De Boulle

Address: Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette,
Belgium

Email: matthias.deboulle@gmail.com

Telephone: +32 2 477 60 09

Fax: +32 2 477 68 51

\emph{Keywords:}

Drug Eluting Stent

Atherosclerosis

Leriche syndrome

\emph{Key clinical message}

Transcarotid percutaneous coronary intervention is feasible and safe,
and can be considered as an ultimate alternative in cases where
conventional peripheral vascular access is unavailable.

\emph{Abstract}

Vascular access for percutaneous coronary intervention (PCI) is usually
obtained through the radial or femoral, and to lesser extent the
brachial or ulnar artery. We describe the transcarotid approach for PCI
in a patient with severe peripheral artery disease. No adverse
neurological or cardiac events were observed.

\emph{Text}

\emph{Introduction}

Vascular access for percutaneous coronary intervention (PCI) is gained
via a peripheral artery, mainly the radial or femoral artery. Other less
frequently used access sites include the brachial and ulnar artery (1).
In this article, we present a patient in which conventional arterial
access sites where inaccessible due to severe peripheral artery disease,
and where access was obtained at the left carotid artery for PCI of the
left anterior descending coronary artery (LAD).

\emph{Case report}

A 64-year-old woman, without prior cardiac history, was admitted to the
hospital with worsening dyspnea on exertion, orthopnea and swelling of
the lower limbs. She had hypercholesterolemia and prediabetes and was an
active smoker. Clinical examination showed signs of congestion. A
transthoracic echocardiogram revealed a dilated left ventricle with
severe left ventricular dysfunction, with a left ventricular ejection
fraction of 25\%. The diagnosis of congestive heart failure was made.
Medical heart failure therapy was initiated.

To rule out underlying coronary artery disease, an invasive coronary
angiography was planned. However, vascular access could not be obtained
despite several attempts via different arterial access points, both
radial and femoral. A computed tomography angiography (CTA) as well as a
coronary computed tomography angiography (CCTA) were performed. The CTA
showed extensive peripheral artery disease, with a total occlusion of
the infrarenal aorta and both common iliac arteries (Leriche Syndrome),
a total occlusion of both subclavian arteries, and a critical stenosis
of the brachiocephalic artery (Figure 1), explaining the inability to
obtain access through conventional access sites. Furthermore, there was
a severe stenosis of the left internal carotid artery, and a mild
stenosis of the left common carotid artery. However, arterial access
could be obtained proximally at the left carotid artery. The CCTA showed
extensive coronary calcifications, with a severe stenosis in the LAD, a
moderate stenosis in the right coronary artery (RCA) and a moderate
stenosis in the left circumflex artery (LCx), and thus justified the
need for coronary artery revascularization.

After multidisciplinary Heart Team discussion, involving the vascular
surgeon, the decision was made to perform PCI of the LAD via the left
carotid artery.

The configuration of the catheterization lab was adjusted to enable
carotid access site preparation and PCI (Figure 2). The procedure was
performed under general anesthesia. First, the vascular surgeon made the
skin incision along the anterior border of the sternocleidomastoid
muscle. The subcutaneous tissue and platysma were incised. The sheath
over the common carotid artery was opened and the artery encircled with
a vessel loop. After that, a retrograde puncture of the artery was
performed and a guidewire with a 6 French sheath were positioned in the
aortic arch under fluoroscopy. To ensure that the sheath stayed fixated,
it was sutured to the sternocleidomastoid muscle (Figure 3). A
diagnostic coronary angiogram was then made by the interventional
cardiologist. The presence of a severe stenosis in the mid segment of
the LAD and moderate stenoses in the RCA and LCx were confirmed. PCI was
performed, with deployment of a XIENCE Sierra? 2.75 x 38 mm drug eluting
stent (Abbott, Santa Clara, CA, USA) in the mid LAD. Adequate stent
expansion and complete stent apposition were achieved, confirmed by
angiography and intravascular ultrasound (IVUS) (Figure 4). Finally, the
vascular surgeon removed the sheath, closed the puncture hole with a
prolene suture, and sutured the overlying tissues and skin.

The length of the combined procedure was 111 minutes, with a total
fluoroscopy time of 14 minutes. The total dose area product (DAP) was
25.311 Gy.cm\textsuperscript{2}, with a total air kerma (K) of 318 mGy.
A total of 150 ml of iodinated contrast was used. During the procedure,
5000 units of unfractionated heparin were given. The patient received
dual antiplatelet therapy, consisting of acetylsalicylic acid 80mg and
clopidogrel 75mg once daily.

During the postoperative observation period, the patient showed good
vital signs, no chest pain and no neurological symptoms. She was
discharged from the hospital the next day.

\emph{Discussion}

The transcarotid approach has been described as a viable alternative for
vascular access in several other procedures, such as aortic repair
interventions (2), cerebral angiography (3), endovascular intervention
for acute ischemic stroke (4,5), complex pediatric cardiac interventions
(6,7), and transcatheter aortic valve implantation (TAVI) (8--10). One
case of a diagnostic coronary catheterization via transcarotid approach
has also been described (11). This is, to our knowledge, the first
reported adult case of a PCI via transcarotid approach.

In a recent meta-analysis, comparing transcarotid versus transfemoral
TAVI, transcarotid TAVI seems to be non-inferior to transfemoral TAVI in
terms of overall mortality and short-term neurological complications
such as transient ischemic attack and stroke (8). As such, safety for
performing transcarotid percutaneous interventions has been
demonstrated. Since our current experience is limited to this case
alone, we cannot make general conclusions regarding the safety of PCI
via transcarotid approach. Nonetheless, our patient experienced no
adverse neurological or cardiac events during or after the procedure.

For this procedure, the configuration of the catheterization lab was
different than the usual configuration used for PCI via the radial or
femoral approach. Apart from this adjusted catheterization lab
configuration, the materials used for the PCI were the same as what is
normally used, including a standard sheath and standard coronary
catheters.

\emph{Conclusion}

Our case demonstrates that transcarotid PCI is feasible. The
transcarotid approach can be considered as an ultimate alternative in
cases where conventional peripheral vascular access for PCI is
unavailable.

\emph{Acknowledgement}

We thank Margot Allonsius for taking and processing the periprocedural
images.

\emph{Author contributions}

Matthias De Boulle: literature research, manuscript writing

Eric Debing: manuscript correction and writing

Dries Belsack: data processing, manuscript correction

Bert Vandeloo: literature research, manuscript correction

References

1. Kolkailah AA, Alreshq RS, Muhammed AM, Zahran ME, Anas El-Wegoud M,
Nabhan AF. Transradial versus transfemoral approach for diagnostic
coronary angiography and percutaneous coronary intervention in people
with coronary artery disease. Cochrane Database Syst Rev. 2018 Apr
18;4:CD012318.

2. Wee I, Syn N, Choong A. Carotid Access For Aortic Interventions:
Genius Or Madness? Vasc Endovasc Rev. 2018 Sep 23;1:38--42.

3. Bauer J, Salazar JL, Sugar O, Pawl RP. Direct percutaneous cerebral
angiography in neurosurgical practice. J Neurosurg. 1980
Apr;52(4):525--8.

4. Cilingiroglu M, Hakeem A, Wholey M, Goktekin O. Direct carotid access
for endovascular management of acute ischaemic stroke. EuroIntervention
J Eur Collab Work Group Interv Cardiol Eur Soc Cardiol. 2017 Oct
13;13(9):e1120--1.

5. Colombo E, Rinaldo L, Lanzino G. Direct carotid puncture in acute
ischaemic stroke intervention. Stroke Vasc Neurol. 2020 Jan
29;5(1):71--9.

6. Davenport JJ, Lam L, Whalen-Glass R, Nykanen DG, Burke RP, Hannan R,
et al. The successful use of alternative routes of vascular access for
performing pediatric interventional cardiac catheterization. Catheter
Cardiovasc Interv Off J Soc Card Angiogr Interv. 2008 Sep
1;72(3):392--8.

7. Polat TB. Use of percutaneous carotid artery access for performing
pediatric cardiac interventions: Single-center study. Ann Pediatr
Cardiol. 2020;13(1):16--24.

8. Wee IJY, Stonier T, Harrison M, Choong AMTL. Transcarotid
transcatheter aortic valve implantation: A systematic review. J Cardiol.
2018 Jun 1;71(6):525--33.

9. Folliguet T, Laurent N, Bertram M, Zannis K, Elfarra M, Vanhuyse F,
et al. Transcarotid transcatheter aortic valve implantation: multicentre
experience in France. Eur J Cardio-Thorac Surg Off J Eur Assoc
Cardio-Thorac Surg. 2018 Jan 1;53(1):157--61.

10. Modine T, Lemesle G, Azzaoui R, Sudre A. Aortic valve implantation
with the CoreValve ReValving System via left carotid artery access:
first case report. J Thorac Cardiovasc Surg. 2010 Oct;140(4):928--9.

11. Lichtenwalter C, Guleserian KJ, Holper EM. Carotid access for
cardiac catheterization: revisiting the past for a complex
intra-arterial approach. Cardiovasc Revasc Med. 2011 Mar
1;12(2):134.e1-134.e5.

\emph{Figures}

\emph{Figure 1}

Computed tomography angiography showing a total occlusion of the
infrarenal aorta and both common iliac arteries (arrows), and a total
occlusion of both subclavian arteries (arrowheads).

\emph{Figure 2}

The configuration of the catheterization lab, which allowed for carotid
access site preparation and percutaneous coronary intervention.

\emph{Figure 3}

A perioperative view, showing the left common carotid artery with a 6
French sheath fixated to

the sternocleidomastoid muscle.

\emph{Figure 4}

Angiographic view of the severe mid left anterior descending artery
stenosis, before (a) and after (b) percutaneous coronary intervention
with implantation of a drug eluting stent.\selectlanguage{english}
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