Transcervical Carotid Artery Stenting via Cut-down Access in Multifocal Atherosclerosis: Technical Note

Background: Carotid atherosclerotic diseases are managed with carotid endarterec-tomy or carotid artery stenting, both associated with low risks of stroke and mortality during the procedure. However, in cases of severe carotid artery disease where the vessels are tortuous or the femoral or radial arteries are occluded, conventional access methods can be challenging. In such situations, direct puncture via the cut-down technique of the carotid artery offers an alternative approach for stenting severe stenosis. Case presentation: Two patients (75 and 57 years old) presented with a right-sided hemiparesis and a history of transient ischemic attacks, strokes, or amaurosis fugax corresponding to a carotid stenosis of ≥50% and of ≥90%. Femoral angiography of both patients showed occlusion of the common and internal iliac arteries. The surgical procedure entailed a direct carotid artery puncture with a microsurgical dissection technique to expose the carotid artery within a neuroendovascular operating room under general anesthesia. All subsequent endovascular procedures were conducted through the sheath. Following the completion of the endovascular intervention, the sheath was removed, and closure of the puncture sites was directly achieved using either Prolene sutures or a purse-string suture technique. The patients had a smooth postoperative recovery devoid of neurological deficits. Conclusions: Direct carotid artery puncture via the cut-down method for carotid artery stenting promises procedural safety, precision, and good clinical outcomes, despite potential cost increases and specialized personnel needs.