Alternative Transcarotid Approach for Endovascular Treatment of Acute Ischemic Stroke Patients: A Case Series / 신경중재치료의학

PURPOSE: Mechanical thrombectomy has become the standard of care for acute stroke caused by large vessel occlusion. As more patients are treated endovascularly, the number of older patients with tortuous vessels has risen. In these patients, catheterizing the internal carotid artery via a transfemoral approach can be very difficult or even impossible. Therefore, in selected patients, alternative strategies to the transfemoral approach have to be applied. MATERIALS AND METHODS: We report a case series of six patients undergoing mechanical thrombectomy via a combined transfemoral and transcarotid approach. Puncture of the carotid artery was conducted using roadmap guidance after an unsuccessful transfemoral attempt. Technical aspects and outcomes with this alternative approach were analyzed. RESULTS: Direct puncture of the carotid artery was achieved in five out of six patients (83%). In three out of six patients (50%), revascularization (modified Thrombolysis in Cerebral Infarction score ≥2b) was restored. No complications related to endovascular therapy were documented. One patient showed good neurological outcome (modified Rankin Scale [mRS] 5 at admission, mRS 1 at discharge). CONCLUSION: A combined transfemoral/transcarotid approach can be an alternative vascular access in patients with problematic vessel anatomy.

Neutral versus 45 degree rotated position of head for internal jugular vein cannulation: A comparative study based on ultrasonography.

Background: Most of the methods do not specify its optimal degree of head rotation during central venous catheterization. Aims & Objective: To compare neutral versus 45 degree rotated position of head for internal jugular vein (IJV) cannulation based on ultrasonography. Material and Methods: This prospective, randomized study was conducted in a teaching and tertiary care hospital. Randomly selected 100 healthy volunteers were placed supine with 15º trendelenberg position. Head of the volunteer was kept neutral in group N (100 volunteers) and 45º rotated in group R (100 volunteers). 7.5 M Hz linear array probe of a portable ultrasound was placed perpendicular to the apex of triangle formed by two heads of sternocleidomastoid muscle and clavicle. We simulated a line as a needle insertion on ultrasound screen passing the mid-point of the IJV. A “hit” was defined as the intersection of the inner lumen of carotid artery (CA) by simulated line. The observations were recorded for both sides of neck for each group. Student’s t test was applied for quantitative data and Fisher exact test for qualitative data. P value < 0.05 was taken as significant. Results: The frequency of ‘Hit’ was less in group N than R (right side: 5% versus 15%, p=0.0317; left side: 15% versus 28% p=0.0381). Total frequency of ‘Hit’ was less in right side than left side for both groups (p<0.05). The diameter of IJV and CA were comparable in both groups for right and left side of neck (p>0.05). The distance of IJV from skin was more in group N than R (right side: 10.29±1.88 versus 9.75±1.88, p=0.0436; left side: 10.75±1.87 versus 10.21±1.86, p=0.0416). Conclusion: A neutral position was safer than 45 º neck rotation during IJV cannulation with regard to CA puncture.

Embolization of Anterior Communicating Aneurysm associated with Interrupted Aortic Arch / 신경중재치료의학

Interrupted aortic arch (IAA) is an interruption in the continuity of the aortic arch, often with a fibrous cord between the two segments. It accounts for about 1% of congenital cardiovascular defects and is differentiated from severe coarctation and aortic atresia by the absence of any structural connection (1). Survival may be prolonged because effective arterial collaterals to the descending aorta develop during fetal and postnatal life (2). Although only two cases reported a combination between IAA and an aneurysm of the circle of Willis, there is none of report in coil embolization of the same case. We describe a 31-year-old patient, in whom IAA and unruptured aneurysm were discovered during angiography. Coil embolization was performed via direct puncture of the common carotid artery, which was required due to arterial tortousity and interruption.