Hybrid Retrograde Stenting for Symptomatic Innominate Artery Stenosis

Abstract

Innominate (brachiocephalic) artery stenosis is a rare but important cause of cerebrovascular events, accounting for <2% of extracranial cerebrovascular disease. Clinical presentations include transient ischemic attacks (TIAs), cerebrovascular accidents (CVA), and upper extremity ischemia. Diagnosis is frequently delayed due to symptomatic overlap with carotid and intracranial pathology. Endovascular stenting is increasingly favored over open bypass, although reported experience remains limited compared with open revascularization. In addition, the optimal site access and embolic protection strategy remain topics of debate. The presented case involves a 64-year-old woman who developed recurrent transient left hemibody weakness. Carotid artery evaluation including Computed Tomographic Angiography (CTA) and duplex ultrasound, revealed no significant stenosis within the carotid vessels. Subsequent review of CTA of the head and neck demonstrated severe calcific plaque throughout the brachiocephalic artery with filling defects suggestive of adherent thrombus.  The patient was started on apixaban by cardiology as an outpatient. Despite therapy, her symptoms progressed, prompting emergency department referral for TIA evaluation. The patient underwent a hybrid retrograde innominate artery stenting via surgical right common carotid artery (RCCA) access. This case highlights the importance of considering proximal great vessel disease in patients with unexplained cerebrovascular symptoms and the diagnostic and therapeutic challenges posed by innominate artery disease.