Difficult Access: Tips and Tricks

Abstract

Access to the carotid artery for the delivery of a stent must be performed safely for carotid angi-oplasty and stenting (CAS) to be a viable treatment option. Carotid access includes the following steps: arch assessment, carotid artery catheterization, passage of an exchange guidewire, and placement of a guiding sheath into the common carotid artery (CCA) in proximity to the target carotid bifurcation. The requirements of carotid access are that the sheath must be placed safely and, once in place, that it remain stable for the duration of the procedure. Achieving carotid sheath access may be straightforward in a patient with simple u-shaped arch, great vessels arising from the top of the arch, minimal tortuosity of the branches, and no extra lesions involving areas outside the carotid bifurcation. Unfortunately, the challenge faced in achieving access is often much greater, and is dependent on one's ability to identify, understand, and manipulate difficult anatomy. This chapter reviews anatomical consideration for carotid access, describes difficult access anatomy, and offers tips for managing the difficult carotid access.