proximal balloon protection PBP 5 TB-CAS 症例呈示 76 2 internal carotid artery; ICA 5 NIHSS 5 MRI MRA ICA ICA middle cerebral artery; MCA tpa 100 mg/ 75 m

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1 テクニカルノートバルーン付きガイディングカテーテルを用いた経上腕動脈アプローチによる proximal balloon protection 下の頚動脈ステント留置術 : 9Fr Optimo を用いたシースレス法 Carotid artery stenting under proximal balloon protection via the transbrachial approach using a balloon guiding catheter: sheathless method with 9Fr Optimo Junpei KOGE Ichiro NAKAHARA Tsuyoshi OHTA Shoji MATSUMOTO Nobutake SADAMASA Ryota ISHIBASHI Masanori GOMI Makoto SAKA Takuya OKATA Kazutaka SONODA Hidehisa NISHI Haruka MIYATA Sadayoshi WATANABE Izumi NAGATA Department of Neurosurgery, Stroke Center, Kokura Memorial Hospital Abstract Objective: Proximal balloon protection (PBP) in carotid artery stenting via the transbrachial carotid artery stenting (TB- CAS) approach has not been feasible because a large-sized sheath introducer is required. We report a novel technique of TB-CAS using sheathless balloon guiding catheter navigation. Case presentation: A 76-year-old male presented with a symptomatic left internal carotid artery stenosis. Transfemoral approach was difficult because of severe arteriosclerosis obliterans. A 9Fr Optimo 90 cm was inserted into the right brachial artery over a 6Fr long dilator 108 cm by the coaxial method without sheath introducer, and it was advanced into the right subclavian artery. A long dilator was exchanged with an inner catheter and a 9Fr Optimo was navigated into the common carotid artery by using the telescoping technique. Further procedures were successfully performed by PBP using a 9Fr Optimo. The patient's postoperative course was uneventful, and follow-up head MRI did not reveal any distal embolization. Conclusion: This technique is useful in high-risk patients of distal thromboembolic complication in CAS with difficult femoral access, because it enables PBP by TB-CAS. Key words carotid artery stenting, transbrachial approach, balloon guiding catheter, proximal balloon protection, sheathless j.kouge@gmail.com Received December 24, 2014 Accepted February 9, 2015 doi: /jnet.tn 緒言 carotid artery stenting; CAS transbrachial approach CAS TB-CAS 1 4 TB-CAS 6Fr vulnerable plaque 1

2 proximal balloon protection PBP 5 TB-CAS 症例呈示 76 2 internal carotid artery; ICA 5 NIHSS 5 MRI MRA ICA ICA middle cerebral artery; MCA tpa 100 mg/ 75 mg/ 60 mg/ 6 NIHSS MRI ICA cm/sec Black blood MRI T I-IMP N-isopropyl-p-[123I]iodoamphetamine single photon emission CT acetazolamide Powers' stage / 3D CTA ICA North American Symptomatic Carotid Endarterectomy Trial NASCET 95 ICA tandem lesion cross flow 3D CTA bovine arch Fig mm Fig. 2A ABI ankle brachial pressure index cm/s cm/s ICA tandem lesion carotid endarterectomy; CEA CAS plaque vulnerability PBP TB-CAS 18 4Fr flow reversal system 4Fr 4Fr 4Fr SY-3 external carotid artery; ECA Radifocus 2

A B C Fig. 1 A: A lateral view of three-dimensional rotation angiography (3D-RA) showing severe stenosis (arrow) in the left proximal cervical internal carotid artery (ICA).

3 A B C Fig. 1 A: A lateral view of three-dimensional rotation angiography (3D-RA) showing severe stenosis (arrow) in the left proximal cervical internal carotid artery (ICA). B: An anteroposterior view of 3D-RA showing another severe stenosis (arrow) in the left distal cervical ICA above Fig. 1A. C: A left anterior oblique view of 3D CT angiography showing prominent calcification in the aortic arch. Note the origin of the left ICA presenting bovine arch (arrow) " 300 cm ECA 4Fr Exchange 9Fr 3.07 mm 9Fr 6Fr OPTIMO 9Fr ST 90 cm 6Fr 108 cm 2.21 mm OPTIMO 6Fr 4 6Fr CATHEX JB-2 OPTIMO common carotid artery; CCA Fig. 2B, C activated clotting time ACT 300 Carotid Guardwire 200 cm Medtronic, Minneapolis, MN, USA ECA OPTIMO Carotid Guardwire 200 cm inflate flow reversal system 1 Carotid Guardwire 300 cm ICA tandem lesion ICA petrous portion ICA ECA CCA Fig. 2D ICA SHIDEN 3 mm 40 mm 8 30 Carotid Wallstent Stryker, Minneapolis, MN, USA 10 mm 31 mm Rx-genity 4.0 mm 20 mm 8 30 tandem lesion tandem lesion PBP Integrity 3.0 mm 30 mm Medtronic, Minneapolis, MN, 3

A B C D E Fig. 2 Transbrachial carotid artery stenting (CAS) procedure. A: Preoperative right brachial artery angiography. The diameter of the brachial artery measures approximately 3.7 mm.

4 A B C D E Fig. 2 Transbrachial carotid artery stenting (CAS) procedure. A: Preoperative right brachial artery angiography. The diameter of the brachial artery measures approximately 3.7 mm. B: A plain X-ray view. A Simmons-type coaxial catheter is advanced into the left external carotid artery over a standard-type inch guidewire, which is exchanged to a 300 cm long type. A 9Fr Optimo (white arrow) with a 4 6Fr JB2 catheter (black arrow) is navigated into the left common carotid artery over the long guidewire (arrowhead). C: Lateral view of the left carotid angiography showing severe stenosis and near occlusion in the left internal carotid artery. D: Proximal balloon protection is achieved by 9Fr Optimo in the common carotid artery (black arrow) and by Carotid Guardwires in the internal carotid artery (white arrow) and external carotid artery (arrowhead). E: A lateral view of postoperative left carotid artery angiography showing sufficient dilatation of the stenosis after CAS. USA Carotid Wallstent PRECISE PRO RX 6.0 mm 30 mm Cordis, Johnson & Johnson, Miami, FL, USA 1 Integrity Integrity 3.0 mm 22 mm Medtronic Fig. 2E 4

5 9Fr OPTIMO 7Fr SCU 3 ACT 7Fr 3 CT 8 MRI 28 NIHSS 4 mrs 2 考察 TB-CAS bovine arch 6 kinking 2 2,5 TB-CAS PBP CAS PBP ARMOUR trial EMPiRE Clinical study PROFI study embolic protection device 7 9 PBP flow reversal 10,11 PBP OPTIMO CELLO PATLIVE MOMA ultra Medtronic, Minneapolis, MN, USA 8 9Fr intra-aortic balloon pumping IABP 7.5 8Fr 12,13 Access study Fr IABP 2.52 mm 8Fr IABP 3.26 mm 14 8Fr 15 6Fr 9Fr OPTIMO Fig. 3 PBP TB-CAS 9Fr OPTIMO Table 1 9Fr OPTIMO 3.00 mm 6Fr mm 7Fr Shuttle 6Fr PBP PBP CCA protection Carotid Guardwire CCA/ECA protection 8 mm CCA/ECA protection 9Fr 5

6 A B C Fig. 3 Schema of navigation of 9Fr Optimo to the common carotid artery. A: A 4Fr short sheath is removed, while a inch, 300 cm long guidewire is kept up to the left external carotid artery. B: Enlargement of the skin orifice using a 9Fr short dilator. C: A 9Fr Optimo is inserted into the brachial artery over a 6Fr long dilator by the coaxial method. Table 1 Size chart of guiding catheter/guiding sheath and their utilizability in carotid artery stenting Name of guiding catheter / guiding sheath Outer diameter (mm) Inner diameter (mm) Length (cm) CCA protection CCA/ECA protection using Carotid Guardwire in ECA 8Fr OPTIMO possible impossible 6Fr FUBUKI impossible impossible 6Fr Shuttle impossible impossible 6Fr Destination impossible impossible 9Fr OPTIMO possible possible 7Fr Shuttle , 90 impossible impossible CCA: common carotid artery, ECA: external carotid artery Outer diameter of 6Fr Shuttle is the measured value, because detailed information is not provided by the supplier. stent-retriever Penumbra system ADAPT A direct aspiration first pass technique CCA balloon inflate OPTIMO 3.0 mm 3.7 mm OPTIMO tips 9Fr Optimo+6Fr 3.00 mm 9Fr 1 mg 0.5 mg 17 3 mm 6Fr CCA TB-CAS CCA balloon inflate deflate 6

7 CAS OPTIMO 結語 proximal protection 文献 1 1 No Shinkei Geka 2008; 36: JNET 2007; 1: No Shinkei Geka 2007; 35: Al-Mubarak N, Vitek JJ, Iyer SS, et al. Carotid stenting with distal-balloon protection via the transbrachial approach. J Endovasc Ther 2001; 8: Iwata T, Mori T, Miyazaki Y, et al. Initial experience of a novel sheath guide for transbrachial carotid artery stenting: technical note. J Neurointervent Surg 2013; 5: Montorsi P, Galli S, Ravagnani PM, et al. Carotid artery stenting in patients with left ICA stenosis and bovine aortic arch: a single-center experience in 60 consecutive patients treated via the right radial or brachial approach. J Endovasc Ther 2014; 21: Ansel GM, Hopkins LN, Jaff MR, et al. Safety and effectiveness of the INVATEC MO.MA proximal cerebral protection device during carotid artery stenting: results from the ARMOUR pivotal trial. Catheter Cardiovasc Interv 2010; 76: Clair DG, Hopkins LN, Mehta M, et al. Neuroprotection during carotid artery stenting using the GORE flow reversal system: 30-day outcomes in the EMPiRE Clinical Study. Catheter Cardiovasc Interv 2011; 77: Bijuklic K, Wandler A, Hazizi F, et al. The PROFI study (Prevention of Cerebral Embolization by Proximal Balloon Occlusion Compared to Filter Protection During Carotid Artery Stenting): a prospective randomized trial. J Am Coll Cardiol 2012; 59: Iwata T, Mori T, Tajiri H, et al. Safety and effectiveness of emergency carotid artery stenting for a high-grade carotid stenosis with intraluminal thrombus under proximal flow control in hyperacute and acute stroke. J Neurointervent Surg 2013; 5: Nikas DN, Ghany MA, Stabile E, et al. Carotid artery stenting with proximal cerebral protection for patients with angiographic appearance of string sign. JACC Cardiovasc Interv 2010; 3: Onorati F, Bilotta M, Pezzo F, et al. Transbrachial insertion of a 7.5-Fr intra-aortic balloon pump in a severely atherosclerotic patient. Circ Care Med 2006; 34: Fujii T, Masuda N, Ijichi T, et al. Feasibility of 6 Fr intraaortic balloon pumping via the femoral or brachial approach. J Invasive Cardiol 2012; 24: Kiemeneij F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol 1997; 29: Webber GW, Jang J, Gustavson S, et al. Contemporary management of postcatheterization pseudoaneurysms. Circulation 2007; 115: Marsico F, Ruggiero D, Parente A, et al. Prevalence and severity of asymptomatic coronary and carotid artery disease in patients with lower limbs arterial disease. Atherosclerosis 2013; 228: JNET 2012; 6: JNET 9:00 00, 2015 要旨 Proximal balloon protection PBP Fr 9Fr OPTIMO PBP 7

JNET 9: , 2015 症例報告スーパー政宗 ( 第二報 ) - 初期臨床経験 - Super-Masamune: initial clinical experience Masayuki EZURA, Naoto KIMURA, Hiroshi UENOHARA Departm

JNET 9: , 2015 症例報告スーパー政宗 ( 第二報 ) - 初期臨床経験 - Super-Masamune: initial clinical experience Masayuki EZURA, Naoto KIMURA, Hiroshi UENOHARA Departm JNET 9:192 196, 2015 症例報告スーパー政宗 ( 第二報 ) - 初期臨床経験 - Super-Masamune: initial clinical experience Masayuki EZURA, Naoto KIMURA, Hiroshi UENOHARA Department of Neurosurgery, NHO Sendai Medical Center Abstract