Percutaneous Common Carotid Artery Access for Mechanical Thrombectomy: Reappraisal of a Valuable Alternative Access Strategy in the Setting of Acute Stroke

The cervical approach was the first access used by the pioneers of neuroangiography for neuroendovascular procedures, but it has been surpassed by the femoral and radial approaches and relegated to an infrequently used alternative. This is primarily due to access limitations and other drawbacks, potentially significant complications, and a lack of dedicated hardware. However, in acute ischemic stroke due to large anterior vessel occlusion, access to the target occluded vessel for mechanical thrombectomy via the femoral or radial approach is sometimes impossible. In these cases, direct carotid access can be an alternative, although it is only exceptionally used for intracranial thrombectomy. This 71-year-old man was admitted to the Internal Medicine Department for pneumonia and started on intravenous antibiotics. Four days after admission, he developed speech disturbances and right hemibody weakness. He had a history of poorly controlled arterial hypertension, dyslipidemia, diabetes, and gout and was overweight. He had advanced ischemic heart disease (two transfemoral and seven transradial coronary interventions), congestive heart failure, cerebrovascular disease (previous hospitalization for minor left hemispheric stroke), peripheral vascular disease (severe iliofemoral atheromatosis), hypertensive retinopathy, a history of repeated falls, and stable colon and prostate oncologic conditions. Of note, he had undergone diagnostic coronary angiography via a right axillary approach 3 years earlier. Upon evaluation by neurology residents, the patient had severe motor dysphasia with partial preservation of comprehension, severe right arm paresis, and moderate leg paresis, with a National Institutes of Health Stroke Scale (NIHSS) score of 16. Noncontrast cranial CT performed 5 h after the onset of motor dysphasia and right hemiparesis revealed microvascular brain disease, consistent with an automated Alberta Stroke Program Early CT Score (ASPECTS) of 10. CT perfusion (CTP) images revealed left frontoparietal hypoperfusion (no core, area with Tmax >6.0 s of 37 ml). CT angiography (CTA) showed asymmetric interhemispheric vascularization with suspected occlusion of a left M2 branch. Angiography of the left internal carotid artery (ICA) revealed an early bifurcation of the middle cerebral artery (MCA) stem, giving rise to an upper trunk that bifurcated into a proximal frontal branch and a more distal dominant frontoparietal branch (embolus at M2-M3), with the lower trunk supplying the temporal regions. The patient was taken to the neuro-angiosuite for an urgent intervention to achieve MCA revascularization. Under general anesthesia, we tried unsuccessfully to gain endovascular access via the femoral and radial arteries. We then proceeded to access the left common carotid artery (CCA) via a percutaneous direct cervical approach. A 6F system allowed for a mechanical thrombectomy. At the end of the procedure, the introducer was removed and the artery was manually compressed. The patient rapidly recovered from hemiparesis and remained with mild motor dysphasia (NIHSS 4 on day 7). This chapter focuses on the direct carotid approach as a viable and relatively simple access option in cases in which conventional arterial access is limited or complex access problems are anticipated with the usual routes.