Letter: Transradial Flow-Diverting Stent Placement Through an Arteria Lusoria: 2-Dimensional Operative Video.

Abstract

To the Editor: We read with great interest the article “Transradial Flow-Diverting Stent Placement Through an Arteria Lusoria: 2-Dimensional Operative Video” by Hackett et al.1 The authors present a case of a patient with an arteria lusoria who received effective flow-diverting stent therapy for a large left internal carotid artery (ICA) aneurysm using a large bore guide catheter through right transradial access (TRA). Diagnostic angiography showed that the left ICA could be accessed through the right TRA. A 6F radial sheath was introduced into the right radial artery, and the sheath was then exchanged over a 0.035″ guidewire for an 8F 90-cm guide catheter (Infinity; Stryker Neurovascular). After navigating a 5F 130-cm Simmons catheter into the left common carotid artery through the arteria lusoria, the 8F guide catheter was delivered into the left ICA using the telescoping technique. The large left ICA-ophthalmic artery aneurysm was successfully treated with a pipeline embolization device (Medtronic). The importance of evaluating transradial diagnostic angiography to determine whether a catheter system can safely track into the target supra-aortic vessels is critical for successful transradial neurointervention in patients with arteria lusoria, and we wholeheartedly concur with the authors' conclusion on this point. Cannulation into the supra-aortic vessels through right TRA can be extremely challenging in patients with arteria lusoria because of unfavorable catheter trajectory.2 In addition, the right TRA can cause fatal arteria lusoria dissection.3 Therefore, transfemoral access is frequently employed as first-line access if neurointerventionalists encounter arteria lusoria.2 Previous study reported that left TRA is a technically feasible alternative in neurointerventions for patients with arteria lusoria.4 Nevertheless, a guide catheter may result in a failed TRA that necessitates a crossover to transfemoral access because of a failed cannulation, a kinked catheter, or an unstable system. We have used transradial access as the first-line access for neurointerventions.5-18 The first-line TRA using a 6F preshaped Simmons guiding sheath (outer diameter, 2.70 mm; inner diameter, 0.088″; usable length, 90 cm; 6F Axcelguide Stiff-J; Medikit) offers a large bore working channel and a high procedural success rate without catheter kinking or system instability even in patients with an unfavorable steep supra-aortic take-off.5-7,13 The 6F Simmons guiding sheath is fully engaged into the target common carotid artery with a pull-back maneuver (the pull-back technique) after reforming the Simmons curve within the ascending aorta. The Simmons curve can be reformed by anchoring the 6F Simmons guiding sheath to the descending aorta (the descending aorta anchoring technique) or contralateral subclavian artery (the subclavian artery anchoring technique) through the left TRA. Transradial carotid cannulation with the pull-back technique is technically simple and promising. As a result, left TRA with the 6F Simmons guiding sheath can be a beneficial treatment choice for performing anterior circulation procedures in patients with arteria lusoria. Finally, we would like to express our appreciation to the authors for their interesting article that advances the transradial neurointerventional method.