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Innominate Artery Stenting with Flow-Reversal Neuroprotection: Case Report of Two Surgical Procedures
Brian Ayers1, Scott Cameron1, Sandra Toth1, Adam Doyle1, Xzabia Caliste2, Mark Parsons3, Michael Stoner1.
1University of Rochester, Rochester, NY, USA, 2Albany Medical Center, Albany, NY, USA, 3Reed Eye Associates, Rochester, NY, USA.

Objectives: Flow-reversal neuroprotection systems provide a safeguard against cerebral embolization events during carotid artery stenting procedures. Endovascular procedures involving manipulation of the aortic arch and its branch vessels pose a similar risk of adverse cerebral embolic events. We present two cases in which we utilized a flow-reversal system during stenting of the innominate artery to minimize these risks.
Methods: The first case is an 83 year-old female with crescendo right hemispheric transient ischemic attacks. The second case is a 64 year-old female with a six-month history of crescendo amaurosis fugax. In both cases, computerized tomography angiography revealed substantial stenosis at the origin of the innominate artery, corroborated by duplex hemodynamics. After medical optimization, both cases underwent hybrid revascularization for stroke-risk reduction.
Results: Both operations were conducted utilizing the ENROUTE Transcarotid NPS device (Silk Road Medical Inc, Sunnyvale, CA). The right common carotid artery (CCA) was exposed via a horizontal supraclavicular incision and accessed using a micropuncture needle under direct visualization. The right common femoral vein (CFV) was accessed under ultrasound-guidance. The Silk Road arterial sheath was placed in a retrograde fashion in the CCA and connected to a venous Silk Road sheath placed in the CFV with a clamp subsequently distal to the CCA access site to initiate retrograde flow. Under fluoroscopic guidance, a balloon-expandable stent-graft (iCAST, Atrium USA, Hudson, NH) was placed in the innominate artery in a retrograde fashion, via access from the CCA. A completion angiogram demonstrated technical success without residual stenosis. Both patients were discharged to home the following day with no reported recurrent neurological symptoms at 30-day follow-up.
Conclusions: The ROADSTER prospective trial demonstrated a 1.4% overall stroke rate during carotid artery stenting procedures when utilizing the ENROUTE neuroprotection system. We postulate that flow-reversal protection should be similarly used during procedures of the innominate artery, such as the two presented in this case, to minimize the risk of adverse cerebral events.


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