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Objective: Anatomical factors such as aortic arch elongation or angulation in elderly patients with arteriosclerotic change often make it difficult to perform carotid artery stenting (CAS) via the transfemoral approach under proximal balloon protection (PBP). We report a novel technique of transfemoral CAS using the inner catheter exchange method for a patient with a type III aortic arch. Case Presentations: A 78-year-old man presented with symptomatic left carotid artery stenosis. A balloon guide catheter (BGC) was needed for PBP via the transfemoral approach. Initially, the modified Simmons-shaped inner catheter could not follow the half-stiff long guidewire to the external carotid artery (ECA) by the co-axial method. Accordingly, the inner catheter was safely exchanged with a flexible JB2 catheter with the balloon of the BGC fully inflated on the way to the left common carotid artery (CCA). Following the half-stiff long guidewire and with the JB2 catheter advanced into the distal portion of the left ECA beforehand, the BGC was successfully navigated into the left CCA below the bifurcation. Further procedures were performed without any complications. Conclusion: This technique might be useful in patients with high risk of distal thromboembolic complications in transfemoral CAS with severe elongation of the aortic arch.

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Transfemoral Carotid Artery Stenting Using Proximal Balloon Protection for Patients with Severe Elongation of the Aortic Arch: Inner-catheter Exchange with the Balloon Guide Catheter Anchored (“BGA Exchange”)