• Huan Wang, James L Swischuk, Kenneth Fraser, Jorge Alvernia, and Giuseppe Lanzino.
• Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA.
• Neurosurgery. 2005 Apr 1; 56 (2 Suppl): E441; discussion E441.

Objective And ImportanceAs endovascular neurointerventions continue to evolve rapidly, angioplasty and stenting of both the extracranial and intracranial vessels have become more routine procedures. When the transfemoral approach is contraindicated or technically difficult, familiarity with alternative access techniques becomes essential. We report a successful transaxillary carotid stenting in a patient with an axillary bifemoral bypass graft.Clinical PresentationA 77-year-old man presented with a symptomatic high-grade stenosis (80%) of the left internal carotid artery. Because of the increased risk of general anesthesia related to his advanced age and severe comorbidities, stenting of the left internal carotid artery was considered. A left transaxillary approach was chosen because of the presence of an axillary bifemoral bypass graft.TechniqueUnder ultrasound guidance, the left axillary artery was successfully punctured and cannulated. After a 0.038 Magic Torque wire (Boston Scientific/Medi-Tech, Watertown, MA) was anchored with the tip of the wire in the distal left occipital artery, a 7-French (outer diameter) Vista Bright guiding sheath (Cordis, Miami, FL) was successfully positioned in the mid left common carotid artery, with an MPA catheter (Cordis) used as guiding support. Subsequently, two Precise stents (Cordis) were successfully deployed across the stenosis, yielding a satisfactory angiographic result.ConclusionWith proper patient selection and the use of ultrasound guidance during the initial puncture, the transaxillary approach is a safe and technically feasible alternative to the transfemoral approach when performing carotid stenting.

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