Karas Patrick J, Srinivasan Visish M, Burkhardt Jan-Karl, Kan Peter
Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.
Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Oper Neurosurg (Hagerstown). 2021 Jan 13;20(2):E126-E127. doi: 10.1093/ons/opaa379.
Emergent thrombectomy for large vessel occlusion is now a standard procedure within neurosurgery. In general, thrombectomy is attempted via a femoral artery puncture. However, due to anatomic variability and arterial tortuosity, target vessels cannot be catheterized in roughly 5% of patients.1 Radial artery access is an alternative to femoral artery access; however, target arteries for thrombectomy cannot be catheterized via the femoral or radial arteries in a small subset of patients. Direct carotid puncture is an alternative route of access for emergent thrombectomy in acute stroke.2,3 In this video, we present a patient with an acute right middle cerebral artery occlusion who was taken for emergent thrombectomy after consenting for the procedure. Because of unfavorable arterial anatomy, the right internal carotid artery could not be successfully catheterized via femoral or radial arterial punctures. We ultimately catheterized the right internal carotid artery and middle cerebral artery via a direct carotid puncture. We review the technique for direct carotid puncture, and discuss the outcomes associated with this method of access in the setting of acute large vessel occlusion. We also discuss complications associated with direct carotid puncture. Direct carotid puncture is an acceptable bail-out technique in the setting of emergent thrombectomy when femoral and/or radial access is not possible. Figure at 2:18 republished from Sekhar LN, Iwai Y, Wright DC, Bloom M. Vein graft replacement of the middle cerebral artery after unsuccessful embolectomy: case report. Neurosurgery. 1993;33(4):723-727, by permission of the Congress of Neurological Surgeons. Table at 6:05 modified from Roche A, Griffin E, Looby S, et al. Direct carotid puncture for endovascular thrombectomy in acute ischemic stroke. J NeuroIntervent Surg. 2019;11(7):647-652, ©The Authors, 2019, with permission from Dr Sarah Power. Table at 6:22 reproduced from Jadkhav AP, Ribo M, Grandhi R, et al. Transcervical access in acute ischemic stroke. J NeuroIntervent Surg. 2014:6(9):652-657, ©2013, with permission from the BMJ Publishing Group Ltd.
大血管闭塞的急诊取栓术现已成为神经外科的标准手术。一般来说，取栓术尝试通过股动脉穿刺进行。然而，由于解剖变异和动脉迂曲，约5%的患者无法将导管插入目标血管。桡动脉入路是股动脉入路的替代方法；然而，在一小部分患者中，无法通过股动脉或桡动脉将取栓术的目标动脉导管插入。直接颈动脉穿刺是急性卒中急诊取栓术的另一种入路途径。在本视频中，我们展示了一名急性右侧大脑中动脉闭塞的患者，在获得手术同意后接受了急诊取栓术。由于动脉解剖结构不佳，无法通过股动脉或桡动脉穿刺成功将导管插入右侧颈内动脉。我们最终通过直接颈动脉穿刺将导管插入右侧颈内动脉和大脑中动脉。我们回顾了直接颈动脉穿刺技术，并讨论了在急性大血管闭塞情况下这种入路方法的相关结果。我们还讨论了与直接颈动脉穿刺相关的并发症。当无法进行股动脉和/或桡动脉入路时，直接颈动脉穿刺是急诊取栓术中一种可接受的补救技术。图2:18转载自Sekhar LN、Iwai Y、Wright DC、Bloom M.《取栓术失败后大脑中动脉静脉移植替代：病例报告》。《神经外科》。1993年；33(4):723 - 727，经神经外科医师大会许可。表6:05改编自Roche A、Griffin E、Looby S等。《急性缺血性卒中血管内取栓术的直接颈动脉穿刺》。《神经介入手术杂志》。2019年；11(7):647 - 652，©作者，2019年，经Sarah Power博士许可。表6:22转载自Jadkhav AP、Ribo M、Grandhi R等。《急性缺血性卒中的经颈入路》。《神经介入手术杂志》。2014年:6(9):652 - 657，©2013年，经BMJ出版集团有限公司许可。
