Direct Common Carotid Artery Puncture for Endovascular Treatment of Acute Large Vessel Ischemic Stroke in a Patient With Congenital Rare Variant of the Great Vessels.

Samuel Plant,Biraj M Patel

doi:10.7759/cureus.11127

Samuel Plant, Biraj M Patel

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https://doi.org/10.7759/cureus.11127

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Journal: Cureus	Publication Date: Oct 24, 2020
Citations: 1	License type: cc-by

Affiliation: Carilion Clinic, Virginia Tech

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This report describes a case of acute left middle cerebral artery ischemic stroke that occurred in a patient with unique anatomy of the vessels arising from the aortic arch that remained undiagnosed until the age of 36. The nature of the anatomical variance proved problematic in establishing access to the carotid artery via traditional transfemoral or transbrachial approaches, and direct access was established via left carotid puncture. The patient regained substantial neurologic function. The direct carotid approach described below serves as a viable alternate route to establishing reperfusion in patients with complex or problematic aortic arch anatomy.

Highlights

Congenital variants and abnormalities of the aortic arch are associated with a wide spectrum of symptomology [1] as well as an increased risk of neurological events [2]
It was not known that the patient had any vascular anatomical variance until arch aortogram and several attempts to catheterize the origin of the left common carotid artery revealed the complex anatomical rare variant
Based on a favorable ASPECTS score, plans were made to proceed with endovascular mechanical embolectomy and the patient was transported to the neurointervention suite

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Introduction

Congenital variants and abnormalities of the aortic arch are associated with a wide spectrum of symptomology [1] as well as an increased risk of neurological events [2]. It was not known that the patient had any vascular anatomical variance until arch aortogram and several attempts to catheterize the origin of the left common carotid artery revealed the complex anatomical rare variant. Initial attempts were unsuccessful at catheterizing the LCCA, and subsequent arch aortogram revealed that the patient had an aortic arch anatomy consistent with a congenital vascular rare variant of the great vessels. Given the aforementioned anatomical variant, it was unlikely that a transradial approach to the LCCA would be successful; it was decided to perform a direct left common carotid artery puncture to gain intracranial access. How to cite this article Plant S, Patel B M (October 24, 2020) Direct Common Carotid Artery Puncture for Endovascular Treatment of Acute Large Vessel Ischemic Stroke in a Patient With Congenital Rare Variant of the Great Vessels. Post-embolectomy cerebral angiography demonstrates recanalization of the previously-occluded middle cerebral artery (MCA) branch (black arrow)

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Saver JL