1. A new approach to carotid angioplasty and stenting with transcervical occlusion and protective shunting: why it may be a better carotid artery intervention 
David W Chang, MD, Peter J Schubart, MD, PhD, Frank J Veith, MD, Christopher K Zarins, MD 
Journal of Vascular Surgery 
Volume 39, Issue 5, Pages (May 2004)
DOI: /j.jvs

2. Fig 1
The patient, a 72-year-old man with a rigid C-spine from cervical fusion; chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitus, chronic renal insufficiency, hypertension; and history of congestive heart failure, had transient ischemic attacks. He had been hospitalized for 35 days with respiratory failure after CEA 4 years previously. A, Aortic arch angiogram reveals 360-degree right calcified carotid coil without stenosis and acute 170-degree angulation of left proximal common carotid artery, with aortic arch (1). With difficulty, an MPA guiding sheath was briefly placed in the proximal common carotid artery ostia, but became dislodged during attempts to gain more purchase over the Amplatz wire. Femoral approach carotid angioplasty and stenting would require traversing five angulations of 90 degrees or greater (1-5) to treat this 95% internal carotid artery stenosis. B, Selective carotid angiogram shows pinhole stenosis.
Journal of Vascular Surgery  , DOI: ( /j.jvs )

3. Fig 2
A, Transcervical occlusion and protective shunting was successful after failure of conventional carotid angioplasty and stenting. B, After crossing only the three cephalad severe angulations (1, 2, 3), note the stenosis is now occlusive. C, After stent placement and dilation balloon angioplasty, completion angiogram shows a satisfactory result. The patient was discharged to home the next day.
Journal of Vascular Surgery  , DOI: ( /j.jvs )

4. Fig 3
A through-the-lumen Fogarty catheter (e) is used for temporary occlusion of the external carotid artery. Antegrade flow through the common carotid artery is arrested with a clamp (c) placed on the common carotid artery. Protective shunting of the internal carotid artery blood flow into the jugular vein is accomplished by connecting a 9F common carotid artery sheath (a) to a 6F venous sheath (v) via an interposed 60-μm filter (f). A 5.0 polypropylene suture around the arterial puncture site and a standard vascular tourniquet and umbilical tape (t) looped around the common carotid artery are placed for rapid control of hemostasis.
Journal of Vascular Surgery  , DOI: ( /j.jvs )

5. Fig 4
The patient, a 72-year-old obese man with two episodes of left arm numbness and weakness, underwent carotid angioplasty and stenting with transcervical occlusion and protective shunting. A, Cervical carotid angiogram shows a third 90-degree angulation in the internal carotid artery (a) and an extensive and high lesion (C2). B, After balloon occlusion of the external carotid artery (e) with protective shunting and placement of a Wallstent (C), note resolution of the internal carotid artery kink and the shunted blood in the jugular vein (j). D, Completion angiogram shows a satisfactory result.
Journal of Vascular Surgery  , DOI: ( /j.jvs )

6. Fig 5
Embolic debris collected on the 60-μm filter used in the patient described in Figs 2 and 3.
Journal of Vascular Surgery  , DOI: ( /j.jvs )

7. Fig 6
Patient 1 week after transcervical occlusion and protective shunting, with mini-cutdown incision.
Journal of Vascular Surgery  , DOI: ( /j.jvs )