PMC5386154_01
A: Diffusion-weighted magnetic resonance imaging shows left middle cerebral artery-posterior cerebral artery border zone infarction. B: Magnetic resonance angiography reveals occlusion of the left internal carotid artery. C, D: Lateral views of the left carotid angiogram reveal pseudo-occlusion of the left internal carotid artery.
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F1
He was referred to our medical center at 2 weeks after the onset of transient aphasia and right hemiparesis due to acute brain infarction (Fig. 1A). Magnetic resonance angiography of the neck and the brain showed occlusion of the left ICA (Fig. 1B). Digital subtraction angiography showed anterograde string-like filling of the ICA beyond the carotid bifurcation and showed retrograde filling of the proximal ICA, extending up to the skull base (Fig. 1C, D).
A, B: Computed tomography angiograms show a right-sided aortic arch and the aortic arch branches in the following order: left common carotid, right common carotid, right subclavian, and left subclavian arteries (from proximal to distal). B: The right-sided descending thoracic aorta is seen. C, D: Computerized axial tomography shows the aortic arch passing over the right main stem bronchus. C-E: The aortic arch is observed on the right side of the trachea and the esophagus.
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F2
Aortography showed right-sided aortic arch, and computed tomography angiography was performed to evaluate an access route to the target lesion (Fig. 2A, B). The aortic arch was observed on the right side of the trachea and esophagus (Fig. 2C). The origin of the left subclavian artery was aneurysmal (i.e., Kommerell's diverticulum; Fig. 2D, E).
A: Aortography shows a right-sided aortic arch. B: Kommerell's diverticulum and the left vertebral artery originated from an aberrant left subclavian artery. C: Failure to cannulate the left common carotid artery with a 9-Fr occlusion balloon-guiding catheter via the trans-femoral approach. D: Success in advancing the 6-Fr guiding sheath to the left common carotid artery via the trans-brachial approach.
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F3
 After informed consent was obtained, we performed carotid artery stenting (CAS) for symptomatic left ICA pseudo-occlusion under general anesthesia (Figs. 3, 4). Aichi) was navigated into the descending thoracic aorta on the right side of the trachea using the coaxial method (Fig. 3A, B). After cannulation of the left CCA with the tip of the inner catheter (Fig. 3C), we carefully advanced a coaxially inserted 0.035-inch diameter guidewire into the left maxillary artery. We advanced the 6-Fr guiding sheath over the inner catheter and turned the 6-Fr guiding sheath toward the left CCA just above the aortic valve, and subsequently succeeded in advancing the 6-Fr guiding sheath to the left CCA (Fig. 3D).
Lateral view of the left carotid angiograms before (A) and immediately after (B) initial carotid artery stenting reveals an improved stenotic lesion.
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F4
 After informed consent was obtained, we performed carotid artery stenting (CAS) for symptomatic left ICA pseudo-occlusion under general anesthesia (Figs. 3, 4). Digital subtraction angiography immediately after CAS showed successful stent implantation, and antegrade blood flow of the left ICA was restored (Fig. 4). 