Carotid Stenting in the Bovine Arch

James A. Shaw,1 MBBS, PhD, Edwin C. Gravereaux,1,2MD, and Andrew C. Eisenhauer,1* MD

We report our experience in stent-supported angioplasty of the left internal carotid arteryin patients with anomalous origin of the left common carotid, the so-called bovine arch,in which the right brachiocephalic and left carotid share a common trunk from the aorticarch. The occurrence of the anatomic variant is discussed, and techniques of femoral,brachial, and radial approaches are described. Catheter Cardiovasc Interv 2003;60:566–569. © 2003 Wiley-Liss, Inc.

Key words: carotid artery; stenting; bovine arch

INTRODUCTION

Percutaneous carotid revascularization is used withincreasing frequency to treat carotid atherosclerotic dis-ease [1]. As the technique evolves, experience is beinggained concerning the anatomic and clinical variablesthat influence the procedure. Classically, the procedure isperformed from the femoral approach, with a long sheathplaced into the common carotid artery, and angioplastyand stenting performed through this. The bovine arch inwhich the right brachiocephalic and left carotid share acommon trunk from the aortic arch occurs in 10% of thepopulation [2] and introduces new challenges to the proce-dure. We describe our experience with and the technique ofcarotid stenting in patients with a bovine arch.

CASE REPORTS

Case 1

A 69-year-old man with a history of ischemic heartdisease (IHD) and coronary artery bypass surgery in1996 presented following an episode of amaurosis fugaxinvolving his left eye. Noninvasive studies showed atight stenosis in the left internal carotid (ICA) with a mildlesion in the right ICA and he was referred for percuta-neous intervention. Angiography of the cervical carotidconfirmed a 40% lesion in the origin of the right ICA andcerebral angiography revealed vigorous cross-filling ofthe left hemisphere from the right-sided vessels. The leftcommon carotid artery arose from the brachiocephalicartery (Fig. 1), making selective cannulation potentiallydifficult. The vessel could not be engaged with a DAVcatheter. However, a VTK catheter was able to engageselectively the common carotid and subsequent angiog-raphy revealed a short, severe (90%) stenosis in the leftICA. A 0.035� Glidewire (Boston Scientific/MeditechTerumo, Westwood, MA) was then passed into the ex-ternal carotid artery and the VTK catheter advanced over

it and then exchanged for a 0.035� Amplatz extrastiffwire. Because of the angulation of the takeoff of the leftcommon carotid, it was believed that a 7 Fr Shuttle(Cook, Bloomington, IN) sheath could not be advancedinto the common carotid and thus a more flexible 6 Frwas substituted. This was successfully advanced into thedistal left common carotid. With PercuSurge Guardwire(Medtronic AVE, Danvers, MA) protection, the lesionwas stented with an 8 � 20 mm Precise stent (Cordis,Miami Lakes, FL) and postdilated with a 5 mm ViaTracballoon (Guidant, Santa Clara, CA), yielding a goodangiographic result (Fig. 2). The patient was dischargedhome the following day and at 30-day follow-up heremained asymptomatic.

Case 2

An 87-year-old woman with known diffuse atheroscle-rotic disease and previous stenting of the right ICApresented with transient aphasia and right-sided weak-ness consistent with a left hemisphere transient ischemicattack. Carotid angiography showed a patent stent in theright ICA and a 70% stenosis involving the origin of theleft ICA with the left common carotid artery arising fromthe brachiocephalic artery. She was admitted for stentingand, given the anomalous takeoff of the left common

1Department of Cardiovascular Medicine, Brigham and Wom-en’s Hospital, Boston, Massachusetts2Department of Vascular Surgery, Brigham and Women’s Hos-pital, Boston, Massachusetts

*Correspondence to: Dr. Andrew C. Eisenhauer, Division of Cardio-vascular Medicine, Brigham and Women’s Hospital, 75 Francis Street,Boston, MA 02115. E-mail: aeisenhauer@partners.org

Received 15 May 2003; Revision accepted 5 August 2003

DOI 10.1002/ccd.10690Published online in Wiley InterScience (www.interscience.wiley.com).

Catheterization and Cardiovascular Interventions 60:566–569 (2003)

© 2003 Wiley-Liss, Inc.

carotid artery, it was planned to approach the procedurefrom the right arm. The radial artery pulse was impalpa-ble and absent by Doppler interrogation and thus theright brachial artery approach was used. Percutaneousaccess of the right brachial was obtained and a 6 Fr shortsheath placed. The common carotid was engaged and

cannulated with a 5 Fr internal mammary artery (IMA)catheter (Fig. 3) using a 0.035� Glidewire (Boston Sci-entific/Meditech Terumo) and this was exchanged for anAmplatz extrastiff 260 cm wire. A 6 Fr Shuttle (Cook)sheath was exchanged over this wire and the tip placed inthe left common carotid artery. A PercuSurge Guardwire(Medtronic AVE) was advanced distal to the lesion and,once the distal protection balloon was inflated, the lesionwas predilated and stented with a 10 mm � 40 mmWallstent stent (Boston Scientific/Meditech Terumo).The final result was excellent with minimal residualstenosis (Fig. 4).

Case 3

A 76-year-old man with a history of ischemic heartdisease was referred for carotid stenting following non-invasive testing that showed a severe (� 70%) left ICAstenosis. He was asymptomatic. Diagnostic angiographyrevealed moderate right ICA disease with some cross-filling of the left-sided vessels and the left commoncarotid arose from the brachiocephalic trunk and therewas a 90% left ICA stenosis. Because femoral access hadbeen obtained for the angiogram, it was hoped to be ableto proceed with the therapeutic portion of the case fromthis approach. Despite using various catheters, including

Fig. 1. Case 1. Selective brachiocephalic trunk angiogramshowing the right common carotid (RCCA) and the left commoncarotid (LCCA), both of which arise from the brachiocephalictrunk (BC). This anomaly is known as a bovine arch.

Fig. 2. Case 1. ICA lesion (arrow) before stenting (left) andafter deployment of an 8 � 20 mm self-expanding stent (right).

Fig. 3. Case 2. Catheter course from the brachial/axillary ar-tery (small arrows) to engaging the origin of the left commoncarotid artery (arrow, LCCA).

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DAV and IMA catheters, adequate support to pass a wireinto the external carotid and to support delivery of aShuttle sheath could not be obtained. Thus, a right radialapproach was chosen. A 6 Fr radial sheath (Cook) wasplaced into the right radial artery. From the radial, theexternal carotid was cannulated using a DAV catheterand 0.035� Glidewire, the DAV catheter was exchangedfor an Amplatz extrastiff wire, and a 7 Fr Shuttle sheathwas placed into the common carotid artery. Using Per-cuSurge Guardwire (Medtronic AVE), the left ICA waspredilated, then stented with a 10 � 30 mm Precise stent(Cordis; Fig. 5) and postdilated with a 5.0 ViaTrac bal-loon (Guidant). On completion of the case, there was noresidual angiographic stenosis and the patient was dis-charged the following day and remained asymptomatic at30-day follow-up.

DISCUSSION

Carotid endarterectomy has been shown to reducestroke rates in symptomatic patients with an ICA stenosisgreater than 50% [3,4] and in asymptomatic patients witha stenosis � 80% [5]. In recent years, large series haveshown the safety and efficacy of carotid stenting intreating these lesions in various patient groups [1,6].

The use of this modality for the treatment of carotidatherosclerotic disease continues to increase [6], espe-cially since the widespread use of distal protection de-vices appears to have reduced distal embolization andneurological events [7]. In a recent randomized trial

comparing carotid stenting with endarterectomy, therewere fewer major adverse events (combination of 30-daystroke, MI, and death) in patients treated with stentscompared to those in whom endarterectomy was per-formed [8]. Thus, from available data, it appears stentingis at least as safe as carotid endarterectomy in patients atincreased surgical risk. However, just as with percutane-ous coronary interventions, technical difficulties may beencountered in carotid procedures. These include peripheralvascular disease, which can thwart access from the femoralapproach, or anatomic anomalies and tortuous vessels thatmake engagement of the carotids with catheters andguides difficult. These situations may lead to problemswith equipment delivery to the target lesion and increasethe chance of procedural complications or failure.

Congenital anomalies of the aortic arch will increasethe technical difficulty of the procedure. The so-calledbovine arch where the right brachiocephalic and leftcommon carotid share a common trunk from the aorticarch is the most common and is reported to occur in upto 10% of patients [2]. Other rarer arch anomalies includean aberrant right subclavian, which occurs in 0.5–1.0%of the population and direct origin of the vertebral artery,which is also seen in 1% of patients [2].

In this series, several techniques were used to dealwith the anatomic anomalies. In the first case, a 5 FrCook VTK catheter was employed from the groin toengage the left common carotid and a smaller sheath (6

Fig. 4. Case 2. Left: Selective angiogram of the left commoncarotid in the LAO projection. The arrow shows the lesion at theorigin of the left internal carotid. Right: Area of the lesion (ar-row) after stenting with 10 � 40 mm Wallstent. Fig. 5. Case 3. Left: An irregular and ulcerated left internal

carotid lesion before intervention (arrow) and after deployment(right) of a 10 � 30 mm Precise stent. The tip of the deliverysheath is seen at the bottom of the right panel (small arrow).

568 Shaw et al.

Fr as opposed to the usual 7 Fr) to provide flexibility forpositioning. In the second case, despite attempts withvarious catheters from the femoral approach, adequateaccess to the common carotid could not be achieved toperform the angioplasty/stenting. Thus, a radial approachwas chosen and, after initially catheterizing the externalcarotid with a 5 Fr Cook DAV catheter, a 7 Fr Shuttlesheath could be exchanged into the common carotid toperform the stenting procedure successfully.

Carotid stenting using a radial approach has beenpreviously described in a patient with a totally occludeddistal aorta [9] and is used safely and commonly inroutine coronary procedures [10]. The brachial approachwas used in the third case because the radial artery wasoccluded.

In summary, the presence of the bovine arch increasesthe level of case difficulty when performing left carotidstenting from the femoral approach. There are at leastthree demonstrated access routes to overcome this prob-lem and we have shown that it is still feasible and safe toperform left carotid stenting using distal protection whenthis anatomic anomaly is present. We believe that theright upper extremity (radial or brachial) approach ispreferable when there is a left carotid target lesion in thepresence of a bovine arch. This provides a simple, safe,and effective alternative to femoral access and may sim-plify the procedure in these cases.

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