Neurol Med Chir (Tokyo) 49, 320¿324, 2009

New Pull-through Technique Using the Superficial
Temporal Artery for Transbrachial Carotid Artery Stenting
—Technical Case Report—
Yutaka MITSUHASHI, Akimasa NISHIO, Taichiro KAWAKAMI,
Kazunori SHIBAMOTO, Tohru YAMAGATA,
Tsutomu ICHINOSE, and Kenji OHATA
Department of Neurosurgery, Osaka City University, Graduate School of Medicine, Osaka

Abstract
Carotid artery stenting (CAS) is an effective and less invasive alternative to carotid endarterectomy for
internal carotid artery (ICA) stenosis, but the guiding catheter is often technically difficult to introduce
into the common carotid artery (CCA) in patients with concomitant atherosclerotic disease in the
peripheral vessels or aorta. A new pull-through technique between the superficial temporal artery (STA)
and the brachial artery was used to deliver the guiding catheter into the CCA safely and steadily. An 83year-old male presented with repeated transient left hemiparesis caused by severe stenosis of the origin
of the right ICA. He also had severe systemic atherosclerotic disease with occlusion of the bilateral
femoral arteries. The innominate artery branched at an acute angle from the aorta. Therefore, catheterization of the right CCA seemed to be impossible using a conventional approach. The guidewire introduced from the right STA was lassoed by a loop snare wire and pulled out of the left brachial artery,
forming the pull-through system. The guiding catheter could be introduced into the CCA from the left
brachial artery over this guidewire. Subsequently, successful stent placement was performed under the
distal protection. This new technique may facilitate safe and stable CAS even in patients with a severely
tortuous access route due to concomitant atherosclerotic disease.
Key words: brachial approach,
superficial temporal artery

carotid artery,

pull-through technique,

Introduction

with its balloon inflated in the external carotid artery (ECA).3,14,16)
Here we describe a new technique to perform
CAS via the left transbrachial approach, a pullthrough method via the right superficial temporal artery (STA), which was used to treat a patient with
symptomatic stenosis of the origin of the right ICA
complicated by severe concomitant systemic
atherosclerotic disease.

Carotid artery stenting (CAS) has recently been
recognized as an effective and less invasive alternative to carotid endarterectomy for the treatment of
internal carotid artery (ICA) stenosis because of the
improvement of protection devices.8,17) In general,
the transfemoral approach has been preferred for
CAS, because of the size of the devices and the relative ease in introducing the guiding catheter into the
common carotid artery (CCA). However, the transfemoral route is occasionally unavailable due to severe atherosclerotic stenosis or aneurysm of the
femoral artery, iliac artery, or aorta. In such cases,
the transbrachial approach can be used to perform
CAS,1,3,14,16) but advancing the guiding catheter into
the CCA may present some difficulties because of
the tortuous access route. Various devices to solve
this problem have been described, including the use
of stiff guidewires or anchoring a PercuSurge
GuardWire (Medtronic, Minneapolis, Minn., U.S.A.)
Received

June 18, 2008;

Accepted

stenting,

Case Report and Technique
An 83-year-old male was admitted to a previous
hospital with angina pectoris and heart failure. During the hospitalization, he also suffered transient left
motor weakness repeated several times a week for 3
months. These transient ischemic attacks (TIAs)
were not suppressed by administration of aspirin
(100 mg/day) and ticlopidine (200 mg/day). Therefore, the patient was referred to our institute after
percutaneous coronary intervention (PCI).
Laboratory examination on admission showed no

January 15, 2009

320

Pull-through Technique Using the STA for CAS
particular abnormality including platelet count of
151 × 103/mm3, prothrombin time of 11.8 seconds,
and activated partial thromboplastin time of 39.4
seconds, except for the elevated brain natriuretic
peptide level of 711 pg/ml suggesting the presence of
severe heart failure. Magnetic resonance (MR) angiography showed severe stenosis of the right cervical ICA. The bilateral femoral arteries could not be
palpated, and MR angiography demonstrated severe
obstructive changes in these arteries. Ultrasonography demonstrated significant stenosis of the right
brachial artery that did not allow PCI through this
artery in the previous hospital. The PCI was completed by the left brachial approach. Therefore, we
performed diagnostic cerebral angiography via the
left brachial artery, which demonstrated a serious
atherosclerotic ectatic change in the aortic arch, and
the right innominate artery branching at an acute
angle (Fig. 1). A 4F Simmons type diagnostic
catheter could be barely inserted into the orifice of
the right CCA, but could not be advanced further
cranially. Severe stenosis (99%) in the origin of the
right ICA was confirmed (Fig. 2), which was considered to be responsible for the TIAs. He had very severe chronic heart failure that did not allow general
anesthesia. The stenosis in the right ICA was located
in a relatively high position at the C2-3 intervertebral
level. Furthermore, he had mild cognitive impairment, so had the risk of unexpected movement during the therapeutic procedure. Therefore, carotid
endarterectomy did not seem to be suitable even under local anesthesia. Planning of CAS via the left
transbrachial approach anticipated that catheterization of the right CCA and stabilizing the guiding
catheter during the therapeutic procedures might be

Fig. 1

Angiogram via the left brachial artery showing the right innominate artery branching at
an acute angle from the aorta, and tip of the
diagnostic catheter placed just in the orifice
of the right common carotid artery.

Neurol Med Chir (Tokyo) 49, July, 2009

321

particularly difficult because of the very tortuous access route. Accordingly, we devised a pull-through
technique between the left brachial artery and the
right STA to achieve smooth and safe catheterization.
Under local anesthesia, 5F and 3F sheath introducers were inserted into the left and right
brachial arteries, respectively. The right STA was
exposed in the preauricular area, and an 18G cannula was inserted into the STA using a cut-down technique (Fig. 3). Systemic anticoagulation was initiated by intravenous bolus administration of 5,000 U of
heparin, and activated coagulation time became 297
seconds. A snare wire with a 7-mm diameter loop
(Goose-Neck Snare SK 700; Microvena, White Bear
Lake, Minn., U.S.A.) was introduced through the
right brachial artery into the right innominate artery. A 0.035-inch 300-cm guidewire was inserted
from the right STA and introduced retrogradely into
the ascending aorta through the right ECA, CCA,
and innominate artery, then the tip of the guidewire
was passed through the loop of the snare wire (Fig.
4A). This guidewire was lassoed in the ascending
aorta with another snare wire with a 25-mm diameter loop (Goose-Neck Snare GN2500; Microvena), introduced from the left brachial artery, and
pulled out of the left brachial sheath, thus completing the STA-brachial artery pull-through system
(Fig. 4B). The 5F sheath in the left brachial artery
was exchanged for a 6F 90-cm kink-resistant guiding
catheter (Super Arrow-Flex sheath; Arrow International, Reading, Pa., U.S.A.). This 6F guiding
catheter with an inner 4F catheter was introduced
into the right CCA along the guidewire, passing
through the loop of the snare wire introduced from
the right brachial sheath (Fig. 4C). Then the 6F guiding catheter was firmly grasped with the loop snare,

Fig. 2

Right common carotid angiogram showing
severe stenosis (arrow) in the origin of the
right internal carotid artery.

Y. Mitsuhashi et al.

322

Fig. 3

Photograph showing the right superficial
temporal artery exposed in the preauricular
area and cannulated.

and stabilized in the left CCA with tension loading
through this snare wire. Next, the guidewire used
for the pull-through method and the 4F inner
catheter were removed. The ICA stenosis was
crossed with a distal protection device (PercuSurge
GuardWire) (Fig. 4D). A 3.5-mm × 20-mm balloon
angioplasty catheter (Gateway; Boston Scientific,
Boston, Mass., U.S.A.) was inserted across the lesion
and predilation (6 atm, 30 sec) was performed, then
an 8-mm × 20-mm stent (Precise; Cordis, Miami,
Fla., U.S.A.) was deployed successfully. Subsequently, postdilation (10 atm, 5 sec) was carried out with a
5.5-mm × 20-mm balloon (Amiia; Cordis) under distal protection. During the procedure, the guiding
catheter was firmly stabilized with the snare loop
wire. Final angiography showed adequate dilation
of the stenosis (Fig. 5). Hemostasis at the puncture
sites of the bilateral brachial arteries was established
by manual compression, the exposed STA was ligated, and the wound was closed with nylon sutures.
The total operation time was 105 minutes.
The patient has not experienced any further
cerebral ischemic episodes during a 5-month followup period.

Discussion
The pull-through technique is a very useful way to
introduce a catheter into a tortuous vessel, and was
first reported in 1988 for interventional treatment of
totally occluded iliac arteries.7,11) The stable wire
tension provided by this technique enables safe and
steady delivery of the catheter. Recently, a
brachiofemoral or brachiobrachial pull-through approach was described for the treatment of lesions in
the innominate, subclavian, or vertebral arteries.9,10)
Here we performed CAS with the pull-through
method between the STA and the brachial artery.
The STA is easy to expose in the preauricular area
using a cut-down technique. The STA runs superficially on the galea, and a 15-mm skin incision is ade-

Fig. 4

Intraoperative photographs and schemas of
the procedure to introduce and stabilize the
guiding catheter. A: The guidewire inserted from the right superficial temporal artery
(asterisk) is introduced retrogradely into the
ascending aorta through the loop of the
snare wire (arrow) delivered from the right
brachial artery. B: This guidewire is
caught by another loop snare wire and
pulled out of the left brachial sheath. C:
The 6F guiding catheter is introduced into
the common carotid artery (CCA) over the
guidewire. D: Even after removing the
guidewire used for pull-through method, the
guiding catheter is fixed in place by the loop
snare (arrow). ECA: external carotid artery, ICA: internal carotid artery, SCA: subclavian artery.

quate. Percutaneous puncture may also be used if
the STA has a straight course.
If the guidewire used for the pull-through method
can be placed across the lesion on a vessel, such as
the iliac, innominate, or subclavian artery, the angioplasty balloon or stent can be delivered over this

Neurol Med Chir (Tokyo) 49, July, 2009

Pull-through Technique Using the STA for CAS

Fig. 5

Right common carotid angiogram showing
the stenosis in the internal carotid artery
adequately dilated (arrow).

guidewire.7,9,11) However, in the present case, the angioplasty and stenting devices had to be delivered
separately into the ICA from the guidewire placed
for the pull-through method through the ECA. A
guiding catheter with a large diameter would be required to deliver both the pull-through guidewire
and the therapeutic devices. Recently, a case of stenosis in the left vertebral artery origin was successfully treated by stent placement using the
brachiobrachial pull-through method.10) An 8F guiding catheter was introduced into the left subclavian
artery from the right brachial artery over the pullthrough system between the bilateral brachial arteries, and devices were delivered for distal protection, angioplasty, and stenting into the left vertebral
artery, as well as the guidewire used for pull-through
method through the 8F guiding catheter. No
hemodynamic events occurred in the forearm
despite the use of the guiding catheter with a relatively large diameter.10) However, use of the smallest
guiding system possible will reduce the possibility of
complications at the puncture site including insufficient blood flow in the forearm.4,5,12)
In our case, the left brachial artery also revealed
some atherosclerotic stenosis, so minimizing the
size of the guiding system was important. The pullthrough guidewire had to be removed to deliver the
devices for following angioplasty and stenting
through the 6F guiding catheter. We did not have
confidence in the stability of the guiding catheter
without the pull-through guidewire. Therefore, we
used the loop snare wire technique for grasping the
guiding catheter, which enabled us to stabilize the
guiding catheter even after removal of the guidewire
used for the pull-through method, and reduce the
size of the guiding catheter. By passing the guidewire for the pull-through method through the loop

Neurol Med Chir (Tokyo) 49, July, 2009

323

snare early in the operation, the guiding catheter
was technically easy to lasso. This technique was
previously used in the subclavian artery for stenting
into the vertebral or basilar artery.18)
Direct access to the cervical CCA has been
proposed in cases with limited transfemoral access
for CAS.2,6,13,15) Hemostasis after percutaneous
direct puncture of the CCA is not considered to be
easy under anticoagulant or antiplatelet agent administration. Hematoma formation from the puncture site might cause serious respiratory complications. Recently, direct cervical carotid access via a
small skin incision was reported.2,13) Direct suture of
the arterial wall allowed by this technique may
reduce the risk of the postoperative hemorrhagic
complication at the puncture site. In the present
case, we also considered this method of direct access to cervical CCA. However, we were concerned
about possible uncooperative and unexpected movements of this patient with cognitive impairment,
which might cause serious complications such as
pulling out of the sheath introducer from the CCA
accidentally during the interventional procedures.
The STA is a small and non-eloquent artery, and
thus hemostasis is relatively easy to obtain. There
are no life-threatening structures around the
preauricular STA. Percutaneous direct access to the
STA carries lower risk of hemorrhagic complications around the access route than direct access to
the cervical CCA.
The present case illustrates that the pull-through
method using the STA is technically feasible and
useful if introduction of the guiding catheter into the
carotid artery is difficult due to a tortuous access
route. The indications for CAS may be extended by
this technique.

References
1)

2)

3)

4)
5)

Akaji K, Tanizaki Y, Hiraga K, Akiyama T, Dembo T:
[A case of carotid stenting via the transbrachial approach in the bovine arch]. No Shinkei Geka 34:
319–323, 2006 (Jpn, with Eng abstract)
Alexandrescu V, Ngongang C, Proumen J, Dejardin
H, Serbanescu R, Horion J, Bour A: Filter-protected
carotid stenting via a minimal cervical access with
transitory aspirated reversed flow during initial passage of the target lesion. J Endovasc Ther 13: 196–204,
2006
Al-Mubarak N, Vitek JJ, Iyer SS, New G, Roubin GS:
Carotid stenting with distal-balloon protection via
the transbrachial approach. J Endovasc Ther 8:
571–575, 2001
Basche S, Eger C, Aschenbach R: The brachial artery
as approach for catheter interventions — indications,
results, complications. Vasa 33: 235–238, 2004
Connors JJ III, Wojak JC: Brachiocephalic angioplasty and stenting: vertebral artery origin, in Connors JJ
III, Wojak JC (eds): Interventional Neuroradiology.
Strategies and Practical Techniques. Philadelphia, WB
Saunders, 1999, pp 493–499

324
6)
7)
8)
9)

10)

11)
12)

13)

14)

15)

16)

17)

18)

Y. Mitsuhashi et al.
Diethrich EB, Marx P, Wrasper R, Reid DB: Percutaneous techniques for endoluminal carotid interventions. J Endovasc Surg 3: 182–202, 1996
Gaines PA, Cumberland DC: Wire-loop technique for
angioplasty of total iliac artery occlusions. Radiology
168: 275–276, 1988
Goodney PP, Schermerhorn ML, Powell PJ: Current
status of carotid artery stenting. J Vasc Surg 43:
406–411, 2006
Harada K, Nakahara I, Tanaka M, Iwamuro Y,
Watanabe Y, Fujimoto M: [Therapeutic strategy and
outcome of stenting for subclavian and innominate
artery occlusive disease]. No Shinkei Geka 32:
151–158, 2004 (Jpn, with Eng abstract)
Kusaka N, Tamiya T, Nishiguchi M, Takayama K,
Nishiura T: Bilateral brachial pull-through technique
for stenting in a patient with stenosis of the vertebral
artery origin: technical case report. Neuroradiology
49: 837–839, 2007
Loose HW, Ryall CJ: Common iliac artery occlusion:
treatment with pull-through angioplasty. Radiology
168: 273–274, 1988
Manninen HI, Kaukanen ET, Ik äaheimo R, Karhap äa äa
P, Lahtinen T, Matsi P, Lampainen E: Brachial arterial access: endovascular treatment of failing BresciaCimino hemodialysis fistulas — initial success and
long term results. Radiology 218: 711–718, 2001
Matsumoto H, Hujita K, Miki J, Tuji N, Terada T,
Itakura T: [Direct carotid approach for carotid angioplasty and stenting with a small incision: A technical case report]. No Shinkei Geka 32: 735–740, 2004
(Jpn, with Eng abstract)
Nanto M, Tsuura M, Takayama M, Hirayama K, Okada H, Naka D, Kamei I: [Carotid artery stenting via a
transbrachial artery: techniques and problems]. No
Shinkei Geka 35: 155–160, 2007 (Jpn, with Eng abstract)
Perez-Arjona EA, DelProsto Z, Fessler RD: Direct
percutaneous carotid artery stenting with distal protection: technical case report. Neurol Res 26:
338–341, 2004
Wu CJ, Cheng CI, Hung WC, Fang CY, Yang CH,
Chen CJ, Chen YH, Hang CL, Hsieh YK, Chen SM,
Yip HK: Feasibility and safety of transbrachial approach for patients with severe carotid stenosis undergoing stenting. Catheter Cardiovasc Interv 67:
967–971, 2006
Yadav JS, Wholey MH, Kunts RE, Fayad P, Katzen
BT, Mishkel G, Bajwa TK, Whitlow P, Strickman NE,
Jaff MR, Popma J, Snead DB, Cutlip DE, Firth BG,
Ouriel K: Stenting and angioplasty with protection in
patients at high risk for endarterectomy investigators: Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351:
1493–1501, 2004
Yoneda K, Matsui O, Sanada J, Kusanagi M, Okamoto Y, Kida S: Usefulness of grasping a guiding
catheter with a loop-snare wire for stent placement
into the vertebrobasilar artery. Cardiovasc Intervent
Radiol 29: 646–649, 2006

Address reprint requests to: Yutaka Mitsuhashi, M.D.,
Department of Neurosurgery, Osaka City University,
Graduate School of Medicine, 1–4–3 Asahi–machi,
Abeno–ku, Osaka 545–8585, Japan.
e-mail: y-mitsuhashi＠mtf.biglobe.ne.jp

Commentary
In this Technical Case Report, the authors describe a
new pull-through technique using the superficial temporal artery (STA). As far as I know, this technique
has not been reported previously, so this is the first
report introducing this new technique. This technique, however, is not difficult at all. This is a combination of the standard technique for carotid artery
stenting (CAS), pull-through technique, transbrachial
holding using the Goose-Neck Snare, and cut-down
technique. The important points of the report are
some modification of each standard technique. The
pull-through technique usually makes a loop between
the femoral artery and brachial artery, but the
authors made the loop between the left brachial artery
and right STA. A 4F or 5F catheter is usually used for
the trans-brachial approach, but they used a 3F
catheter into the right brachial artery. Cut-down of
the common carotid artery is a well-known method
for CAS, but STA is not. Such kinds of small modifications result in a great modification which was not
previously considered. The introduction of a guiding
system is the most important and difficult step in the
CAS procedure, especially in elderly patients. The
CAS procedure will be successful in more than half of
cases if we succeed in introduction of the guiding system. So, it is very important that we have as many
choices for introducing the guiding system as possible
in the CAS procedure for elderly patients. This new
technique will surely be added as one of the choices
for the CAS procedure.
Masayuki EZURA, M.D.
Department of Neurosurgery
Sendai Medical Center
Sendai, Japan
Carotid stenting has been validated on the basis of
randomized clinical trials. Mitsuhashi and colleagues
have developed and shared a clever technique for access to the carotid artery to the catheter. This method
is slightly invasive. However, I think that authors'
method is important under the present conditions
with many patients suffering severe arteriosclerosis in
the aging society.
We also encountered a very difficult case of access
to the carotid artery. In such a situation, the new type
guide wire and coaxial catheter, and also cervical extension with bilateral head rotation may be valuable. I
think endovascular surgery is the most important
procedure to need many options. This technique provides a safe and easy method for access options during carotid stenting.
Yoshifumi KONISHI, M.D.
Department of Neurosurgery
Kyorin University School of Medicine
Mitaka, Tokyo, Japan

Neurol Med Chir (Tokyo) 49, July, 2009