Retrograde approach for innominate artery stenting using flow reversal for neuroprotection in Re-operative carotid field

A case of a 74 year old female with a prior history of right carotid endarterectomy (CEA) followed by carotid interposition bypass with polytetrafluoroethylene (PTFE) graft several years later due to restenosis. At 1 year follow up, she was found to have low velocities in the bypass and reversal of flow in her right vertebral artery indicating proximal stenosis. A computed tomography angiography (CTA) and magnetic resonance angiography (MRA) were obtained showing high grade occlusive lesion at her innominate artery. After an unsuccessful attempt at transfemoral endovascular intervention, the patient was brought back for a transcarotid retrograde approach utilizing ENROUTE ® Neuroprotection System with flow reversal for embolic protection. The lesions was crossed successfully in this approach and a balloon mounted covered stent was deployed using Gore ® VBX stent. There was significant amount of debris in the filter which would have embolized without neuroprotection. Patient was discharged on postoperative day 1 with no neurological deficits. In conclusion, this case highlights a successful use of ENROUTE ® Neuroprotection System flow reversal for retrograde transcarotid approach to treat difficult innominate lesions with satisfactory embolic protection.