Direct access to the carotid circulation by cut down for endovascular neuro-interventions

BackgroundNot all vascular lesions of the brain that are amenable to endovascular treatment are safely accessible via the transfemoral route. We describe our technique of carotid cut down for endovascular access and present a couple of illustrative cases. The increasing number of neurosurgeons performing endovascular procedures, or collaborating with interventional neuroradiologists, suggests that this technique should be revived.MethodsThrough a small transverse neck incision at the level of the thyroid cartilage, the CCA, ICA, and external carotid artery are exposed. After obtaining vascular control with vessel loupes, a purse-string suture is placed in the CCA. Puncture of the artery in the center of the purse string is followed by navigation of a wire, and then a sheath, into the ICA. The neurointervention is then carried out. At the conclusion of the procedure, the sheath is removed from the CCA and the purse string tied to secure the artery.ResultsThis technique has allowed us to successfully access the intracranial circulation in 6 patients with challenging anatomy. We present here 2 of the original cases leading to our increasing use of this technique.ConclusionCarotid cut down for direct puncture of the CCA is a viable option to gain access to the intracranial circulation when the transfemoral route seems difficult or dangerous.