小切開による頸動脈直接穿刺により頸動脈ステントを留置した1例

Direct Carotid Approach for Carotid Angioplasty and Stenting with a Small Incision : A Technical Case Report

　Ⅰ．はじめに

　近年頭頸部血管病変に対する血管内治療が発達し，脳動脈瘤に対するコイル塞栓術および頭頸部主幹動脈狭窄に対するステント留置術の症例が増加しつつある．一般にこれらの病変に対する血管内治療は経大腿動脈的にアプローチすることがほとんどであり，時には上腕動脈からアプローチすることもあるが，動脈硬化が強くアプローチが困難な場合には，頸動脈を直接穿刺することでアプローチする必要がある．頸動脈直接穿刺法は実際に施行される機会は極めて少ないが，アプローチのオプションとしてぜひ身につけておかねばならない手法であると思われる．今回，われわれが施行している頸部小切開を併用した頸動脈直接穿刺法による頸部内頸動脈ステント留置術について症例を呈示する．

　Direct carotid puncture is an important option in endovascular surgery when a guiding catheter is not advanced into the common carotid artery because of arterial tortuosity. However,hemostasis after the procedure is not easy and hematoma formation from the puncture site sometimes causes serious complications. We present our carotid angioplasty and stenting (CAS) method with a direct carotid puncture and a small incision. An 85-year-old male with transient ischemic attack had severe left carotid artery stenosis. CAS was planned considering his age,but arterial tortuosity prevented a guiding catheter from being introduced into the left common carotid artery. Following this,the left common carotid artery was exposed with a small skin incision under local anesthesia,and a direct carotid puncture was made. A 7-French short sheath was carefully advanced and positioned into the left common carotid artery and a self-expandable stent was delivered through it. Upon completion of the procedure,the puncture point of the vascular wall was sutured with 6-0 proline immediately after withdrawing the sheath,and the skin was closed. A direct carotid puncture with a small incision can be performed safely. This method can reliably stop bleeding from the puncture site and also avoid the need for prolonged manual compression of the carotid artery under systemic anticoagulation and antiplatelet therapy. We think our method is useful for accessing corotid artery stenosis when the transfemoral approach is difficult.