Carotid Artery Stenting Using the Snake Hunt Technique for Highly Tortuous Carotid Artery Stenosis: A Technical Note

Abstract

In carotid artery stenting (CAS) for highly tortuous carotid stenosis, it is often difficult to guide rigid devices such as carotid stents. There are various adjunctive techniques using a guidewire: the buddy wire technique, the sheep technique, and the stiff guide technique. We report a case in which the tortuous vessel was straightened and a stent could be inserted. A 64-year-old man with amaurosis had highly tortuous left carotid stenosis. Despite the best medical treatments, he often had transient cerebral ischemic symptoms, so we planned CAS. We could insert the first stent, but the proximal vessel was kinked by the placement of the stent. It was so tortuous that the second stent could not be inserted by adjunctive techniques. Therefore, the proximal balloon was inflated and pulled back to straighten the tortuous vessel, and then we could insert the stent. We named this technique the “snake hunt technique” because it was just like catching a snake given that the tortuous vessel was stretched. This technique could be a troubleshooting step when it is difficult to insert a stiff device such as a stent or balloon even with the use of various adjunctive techniques.

Successful carotid stenting of a carotid arterial dissection after straightening the tortuosity using an inflated balloon guiding catheter and the delivery wire of an anchored stent retriever

“…In the present case, a low-profile stent was too small to achieve appropriate stent apposition because the diameter of the target lesion was 8 mm. Several techniques have been reported for introducing a carotid stent delivery system into a tortuous artery [ 7 , 8 ]. Koge et al.…”

“…Koide et al. [ 8 ] described a “snake hunt technique’’ in which the kinked vessel was straightened by pull-back of an inflated proximal balloon in the case of proximal vessel kinking after stent deployment for carotid artery stenosis. In the present case, we successfully deployed a carotid artery stent, straightening the tortuous artery by pulling on the proximal carotid artery with a BGC and straightening the delivery wire to navigate the carotid artery stent by the SR anchoring.…”