Carotid surgical cut-down technique for neuroendovascular therapy

Abstract

Background

Neuroendovascular therapy is typically performed via the femoral artery, but there are rare cases in which a tortuous upstream angioarchitecture makes it difficult to access the intracranial circulation via this route.

Methods

In this case series, we describe six cases treated by surgical cut-down in the neck, with puncture of the carotid artery. Antiplatelet and anticoagulation agents were used in all cases. The indications for the technique were postsurgical thoracic aortic aneurysm (two cases), postsurgical abdominal aortic aneurysm (one case), major vessel tortuosity of the common carotid artery (two cases) and aortic arch anomaly (one case).

Results

The surgical cut-down technique permitted successful neuroendovascular therapy. Although one patient had a small cervical haematoma, he was treated without surgical evacuation.

Conclusion

Overall, our findings indicate that the surgical cut-down technique is safe and useful for patients in whom the femoral approach is unsuitable.

Introduction

A femoral approach is typically used when performing neuroendovascular interventions. However, a tortuous vasculature or the presence of aortic disease can complicate access to the intracranial circulation via this route. At our centre, we have performed surgical cut-down techniques on the carotid artery in such cases for several years. Here, we report a series of six cases in which a cervical arterial cut-down technique was used.

Methods

Design and patient selection

We identified all cases in which neuroendovascular therapy was performed between 2013 and 2017. Among these, patients who underwent surgical cut-down to the carotid artery to facilitate neurosurgery were identified and studied. Clinical data and the indications for neurosurgery were recorded.

Surgical cut-down technique

All patients received pretreatment for a minimum of one week. Before single-balloon-assisted coil embolisation, patients received 100 mg/day of aspirin. However, before stent-assisted coil embolisation or angioplasty and stenting, patients received dual antiplatelet agents from among clopidogrel 75 mg/day, prasugrel 3.75 mg/day and aspirin 100 mg/day.

Under general anaesthesia, the patient was placed in the supine position with his or her head rotated 30° to expose the side of the neck on which the procedure was to be performed. A pillow was then placed under the shoulders to produce neck extension. The carotid bifurcation was confirmed by ultrasound before a transverse incision was made in a skin crease of the neck where the carotid bifurcation was marked. Dissection was carried out through the platysma and medial edge of the sternocleidomastoid muscle and after identifying the carotid sheath, the internal jugular vein was retracted laterally. The common carotid artery was subsequently isolated, and vessel loops were applied to achieve vascular control. The carotid bifurcation was also exposed.

Next, a purse-string suture was placed in the common carotid artery, using 6-0 Prolene, and the artery was punctured at that site with an 18-gauge Surflo® (Terumo Corporation, Tokyo, Japan). A 0.035-inch Radifocus® (Terumo Corporation, Tokyo, Japan) guidewire was then introduced through the sheath and into the carotid artery under fluoroscopic control, before a 6-French gauge (Fr) Parent Plus (Medikit, Tokyo, Japan) guide sheath was advanced over the wire into the artery. To prevent dislocation of the sheath, a 3-0 Surgilon™ braided nylon suture (Medtronic, Minneapolis, MN, USA) was used to anchor the guiding sheath to the skin. After treatment, the sheath was removed from the common carotid artery under direct vision, and the purse-string suture was tied. After the sheath was introduced, neuroendovascular therapy was performed under systemic heparinisation; the sheath and microcatheter were placed while being continuously irrigated with irrigating solutions. All irrigating solutions contained 10,000 IU/L of heparin, and all patients were given a bolus of 5000 IU.

Results

Patient details

During the study period, neuroendovascular therapy was performed in 1123 patients in our department. Of these, six cases (approximately 0.53%; mean age 69.3 years, range 62–76 years) underwent the surgical cut-down technique to the carotid artery (Table 1). The indications for the technique were postsurgical thoracic aortic aneurysm (two cases), postsurgical abdominal aortic aneurysm (one case), major vessel tortuosity of the common carotid artery (two cases) and aortic arch anomaly (one case). As shown in Table 1, only two cases (see cases 1 and 5) presented with symptoms. Endovascular therapy included coil embolisation of anterior communicating artery aneurysms (four cases), coil embolisation and glue embolisation of a carotid cavernous fistula (one case) and angioplasty and stenting of a symptomatic internal carotid artery dissection (one case). All patients underwent magnetic resonance imaging two days after treatment.

Table 1.

Summary of the six cases that underwent the carotid cut-down technique for neuroendovascular therapy.

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6
Age(years)/sex	74/M	76/F	72/F	67/M	65/F	62/M
Symptoms/clinical status (at presentation)	Transient left hemiparesis	None	None	None	Diplopia, chemosis, exophthalmos	None
Indication for treatment	Rt.ICA dissection	Unruptured A.Com aneurysm	Unruptured A.Com aneurysm	Unruptured A.Com aneurysm	CCF	Unruptured A.Com aneurysm
Reason for cutdown	Postsurgical thoracic aortic aneurysm	Excessive vessel tortuosity at the origin of right common carotid artery	Postsurgical thoracic aortic aneurysm	Bovine arch aberrant subclavian artery	Excessive vessel tortuosity at Rt.ICA	Postsurgical abdominal aortic aneurysm
Antiplatelet agent	Aspirin, clopidogrel	Aspirin	Aspirin	Aspirin, clopidogrel	Aspirin, prasugrel	Aspirin
Complications	Cervical haematoma (no surgical evacuation)	None	None	None	None	None

A.Com: anterior communicating artery; CCF: carotid cavernous fistula; Rt.ICA: right internal carotid artery.

Outcomes of the surgical cut-down technique

A representative example of the cut-down technique is shown in Figure 1 (case 2). Microcatheter introduction and subsequent endovascular therapy were successful in all patients. In a patient who presented with an 11 mm unruptured anterior communicating artery aneurysm, although extravasation occurred during the procedure, this did not lead to any clinical deterioration or focal neurological deficit. After sheath withdrawal, a cervical haematoma formed and compressed the upper airway in another patient. However, the patient was managed conservatively by intubation for a week and did not require surgical evacuation. Diffusion-weighted imaging showed hyperintense lesions in two patients (33.3%), but no patient developed either transient or permanent neurological symptoms.

Figure 1.

Representative case showing the surgical cut-down technique. (a) The carotid bifurcation was detected by ultrasound, and a transverse incision was made in a skin crease of the neck at that site. (b) A 6-0 Prolene purse-string suture was placed in the common carotid artery. The artery was then punctured through the skin with an 18-gauge Surflo® (Terumo Corporation, Tokyo, Japan) at the site of the purse-string suture.

Representative case

A 72-year-old female presented with an asymptomatic, unruptured, anterior communicating aneurysm (case 3). She had previously undergone replacement of the ascending aorta, and three-dimensional computed tomography angiography revealed extreme tortuosity of the descending aorta and acute and more proximal take-off at the brachiocephalic and left common carotid arteries (Figure 2). The aneurysm was treated by a balloon-assisted technique via surgical cut-down (Figure 3). The postoperative course was uneventful, and the patient demonstrated neurological integrity and was subsequently discharged home.

Figure 2.

Representative three-dimensional computed tomography images of case 3. (a) Anterior–posterior and lateral views by computed tomography angiography, demonstrating extreme tortuosity of the descending aorta. (b) Magnified image demonstrating acute and more proximal take-off of the brachiocephalic and left common carotid arteries.

Figure 3.

Angiographic images of the left internal carotid artery in case 3. (a) Anterior–posterior angiographic view of the left internal carotid artery to confirm the position of the distal end of the sheath and ensure that no spasm or dissection was present in the artery. Working-angle angiographic view of the left internal carotid showing the anterior communicating aneurysm before (b) and after (c) treatment.

Discussion

We successfully performed neuroendovascular therapy using the surgical cut-down technique in cases for which the femoral approach was not possible. Although one patient developed a cervical haematoma, he was treated conservatively without requiring surgical evacuation.

Reports indicate that neuroendovascular therapy fails because of access problems in some 1–2% of cases.^1,2 In this study, only six cases (0.53%) had tortuous vasculatures or aortic disease that necessitated an alternative access route. Although the femoral approach might have been attempted, it is known that prolonged or reiterated attempts are associated with an increased risk of ischaemic stroke when the vasculature is tortuous.² In our centre, abnormalities on diffusion-weighted imaging after neuroendovascular therapy have been shown to be lower for the surgical cut-down technique (33.3%) than for the femoral approach (40.3%).³

During neuroendovascular therapy, an advantage of transcervical access via carotid cut-down, compared with the transfemoral approach, is the ability to place the guide catheter safely. The short access route also provides easier navigation of the microcatheter. We fixed the guiding sheath to the skin with a 3-0 nylon suture to prevent both sheath dislocation and focal bleeding during the procedure. It is important that the guide sheath is fixed through the skin to provide the strongest anchor.

A percutaneous direct puncture approach has also been used when the transfemoral approach was not attainable for neuroendovascular therapy.^1,2,4–7 To improve reliability, some authors have used ultrasound guidance, fluoroscopic control or roadmap guidance to introduce the guide catheter into the carotid artery.^4,7 Such approaches are certainly less invasive than the surgical cut-down technique, and upon removing the sheath, haemostasis can usually be achieved by simple manual compression. However, the cut-down technique can minimise the risk of severe cervical haematomas after sheath removal because the purse-string suture is tied under direct visual control at the site of sheath entry into the vessel.

Anticoagulants and antiplatelet medications are also needed to reduce ischaemic complications in neuroendovascular therapy, but this is at the risk of increasing the likelihood of haemorrhagic complications. In a series of percutaneous direct punctures of carotid or vertebral arteries (n = 42), Blanc et al. reported that three (7.1%) resulted in cervical haematomas after sheath removal, with one requiring emergency surgical evacuation.¹ There were no complications when they used a closure device to reduce the incidence of postoperative haematoma (Angio-seal™, Terumo Corporation, Tokyo, Japan). However, this closure device increases the risk of ischaemic complications because an intraluminal anchor is placed to close the puncture site. In other research (n = 27), Nii et al.⁵ reported that a cervical haematoma evolved after percutaneous direct puncture of the carotid artery in only one patient (3.7%). Some case series describing surgical cut-down techniques have reported no cases of postoperative cervical haematoma.^2,8–10 These case series used transverse or longitudinal incisions, from 6-Fr to 8-Fr sheaths, and purse-string suturing. Incisions made longitudinally tended to form larger wounds than transverse incisions.

We speculate that haematoma development was associated with sheath size. For example, Nii et al.⁵ used a 5-Fr sheath in all cases, whereas Blanc et al.¹ used 6-Fr or 8-Fr sheaths in the cases that developed cervical haematomas. However, no cervical haematoma was observed in 33 cases that used a 17-gauge or 5-Fr sheaths. Three of the nine patients (33.3%) who developed cervical haematomas used the higher gauge sheaths.¹ In the present study, 6-Fr sheaths were used in all patients, and one patient (16.7%) developed a cervical haematoma.

Ischaemic complications are possible when percutaneous direct puncture is used because of the need for prolonged manual compression at the puncture site. By contrast, the cut-down technique does not require prolonged manual compression and may avoid this complication. Nii et al.⁵ reported that 7 of 17 patients (41.1%) developed high-intensity signals on diffusion-weighted imaging 2–5 days after treatment. They reported that direct percutaneous puncture and manual compression may have caused the thromboembolic events. In our study, diffusion-weighted imaging showed hyperintense lesions in two of the six (33.3%) patients.

Because neuroendovascular therapy is typically performed by neurosurgeons in Japan, the cut-down technique is not so difficult to perform. However, radiologists and cardiologists who perform neuroendovascular therapy but are not trained in surgical technique should consider asking a neurosurgeon to assist them with cervical cut-down.

Conclusions

The surgical cut-down technique seems to be useful in patients in whom the femoral approach cannot be used. It appears to be particularly effective for patients who require extensive heparinisation, antiplatelet agents or larger luminal sheaths.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.