上腕アプローチでの頚動脈ステント留置術におけるプロテクション法の工夫

A Novel, Less Invasive Protection Method for Carotid Artery Stenting

Ⅰ．緒　　言

　頚動脈ステント留置術（carotid artery stenting：CAS）において，不安定プラークが想定される場合や高度狭窄例では，バルーン付きガイディングカテーテルを用いたproximal balloon protection（PBP）法が安全とされている^1-3,7)．しかしながら，上肢からのアプローチやtypeⅢ大動脈弓の症例ではバルーン付きガイディングカテーテルを誘導できず，distal protectionで行うか，CASは断念せざるを得ない．そこでわれわれは，6Frガイディングシースでも実施可能な信頼度の高いprotection法を編み出した．この方法はやや手技が煩雑となるが，より低侵襲かつ安全にCASが行えるようになったので紹介する．

　Purpose：We present a novel, less invasive protection method for carotid artery stenting.

　Case presentation：A 67-year-old man presented with symptomatic severe left carotid artery stenosis. A transfemoral approach was dangerous because of an abdominal aortic aneurysm. A 6Fr Axcelguide Simmonds catheter was inserted into the right brachial artery, and advanced into the left common carotid artery. Next, a 6Fr Optimo 100-cm catheter was coaxially navigated into the left common carotid artery. A PercuSurge GuardWire 300-cm was coaxially navigated into the left external carotid artery. Under flow reversal with the 2 balloons, another PercuSurge GuardWire 300-cm was navigated into the distal left internal carotid artery through the lesion. After both PercuSurge GuardWire balloons were inflated, the 6Fr Optimo was deflated and retrieved using a catheter exchange technique. Then, under distal double-balloon protection, routine stenting was performed.

　Conclusions：This technique is safer and less invasive than previous methods, especially in cases with difficult femoral access and vulnerable carotid plaque.