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What’s an alternative arterial access site? Why do we need it? Where to access? Who should we select for these strategies?

76-year-old man with right internal carotid artery occlusion. In 2009, left carotid endarterectomy for symptomatic carotid stenosis.

Follow-up protocol with yearly carotid ultrasound and 10 years later an asymptomatic restenosis of 90-95% was diagnosed and proposed for re-intervention.

PAD with severe bilateral aorto-iliac disease. Femoral pulses were absent.

Under local anesthesia, stenting of the left carotid axis (Roadsaver® 8x40mm) by surgical approach of the left primitive carotid artery was performed. SpiderFx 6.0 filter for cerebral protection.

The procedure and the postoperative period were uneventful and the patient was discharged one day after surgery under double antiplatelet therapy. Control ultrasound showed patency of the stent as well as the downstream artery, with no evidence of thrombi or residual stenosis.

This is an interesting and unusual case of in-stent restenosis after CAS.

The patient had been stented on both ICA , left side with dual layer micro mesh stent and right side with an open cell design, Protege, Medtronic.

Restenosis occured on the right side where open cell stent was placed, even though leftside was stented before.

We decided to go for a “stent in stent” solution in order to achieve better result, and Roadsaver stent was chosen for this purpose.

Final result was satisfaying.

A 73-years old female with history of previous left carotid endarterectomy and recent acute transient ischemic attack was referred to our Center to undergo carotid stenting. Her Duplex ultrasound showed severe left internal carotid artery restenosis with significant Doppler flow acceleration.

Carotid artery stenting is a delicate surgery being sometimes as fast as insidious.

We strongly believe that in order to minimize complications rate an almost obsessive attention to details in each procedural moment is essential.

In this video we report probably the most standardized procedure performed at our institution with 6 operators currently doing each passage exactly the same way.

Of course we don’t claim to show the way it should be done, but just the way we learned to do it after more than 3000 performed cases

TCAR is a hibryd option for CAS offering the best cerebral protection with reverse flow system engaging the common carotid artery with the contralateral common femoral vein. The Roadster Trial has the best data never published regarding Peri-operative neurological events for a prospective multicentre Trial. The procedure could be perform under local anesthesia with the patient copletely awake.

Dr. Giovanni Tinelli presents a very comprehensive overview regarding the treatment of the vascular trauma of upper limbs. His presentation includes all relevant information about definition and anatomy, classification of the injury, the different types of treatment and tips from his personal experience.

Clinical Summary
– 28 year old male
– Traumatic aortic injury (TAI)
– Endovascular treatment
Complications
– Aortic arch and brachiocephalic trunk dissection
– Right carotid artery and left sublcavian artery occlusion
– Stroke
– Orthostatic Hypotension (Extracranial Steal Syndromes from Disease of the Aortic Branches?)
Surgery Technique
– Femoro-femoral and right axillary artery cannulation
– The aorta was accessed through a Ministernotomy

1. The heart is accessed through a full midline sternotomy
2. An off-pump coronary artery bypass graft is performed on the left anterior descending artery using a saphenous vein graft and 7-0 prolene continuous suture
3. The aorta is partially clamped with a side clamp and is opened through a longitudinal incision, about 2 cm length
4. A prosthesis is sutured onto the aorta with a continuous 4-0 prolene suture
5. One branch of the prosthesis is passed behind the ascending aorta,