Catheterization and Cardiovascular Interventions 86:480–489 (2015)

Clinical and Procedural Impact of Aortic Arch

Anatomic Variants in Carotid Stenting Procedures
Francesco Burzotta,* MD, PhD, Roberto Nerla, MD, Giancarlo Pirozzolo, MD,
Cristina Aurigemma, MD, Giampaolo Niccoli, MD, PhD, Antonio Maria Leone, MD, PhD,
Silvia Saffioti, MD, Filippo Crea, MD, PR, and Carlo Trani, MD

Objectives: To evaluate the impact of aortic arch variants in patients undergoing carotid
artery stenting (CAS). Background: CAS is increasingly carried out to treat the patients
with internal carotid artery (ICA) stenosis. Aortic arch anatomy may influence its feasi-
bility and affect clinical outcome. Methods: Aortic arch digital subtraction angiography
was systematically performed before CAS. Aortic arch elongation and bovine arch var-
iants were recorded. Catheter manipulation time (CMT) was assessed for each patient.
Adverse cardiovascular and cerebral events were assessed at 30 days. Results: A total
of 282 consecutive patients undergoing CAS under proximal balloon occlusion (57.8%)
or distal filter (42.2%) neuroprotection were enrolled (age, 72 6 7 years; 72.7% males).
Type II and III elongation variants were detected in 23.4% and 10.6% of patients, respec-
tively; in total, 20.5% of the patients had bovine configuration. CMT was significantly
influenced by aortic elongation (56.1 6 16.5 min in patients with type III aortic arch con-
figuration compared to 38.2 6 11.6 min in patients with type I or type II, P < 0.01) and (in
left ICA) by bovine configuration (49.2 6 11.4 min in bovine variants vs. 37.7 6 11.5 min in
patients with nonbovine anatomy, P < 0.001). CMT, but not aortic arch anatomy, resulted
the only independent predictor of 30-day adverse outcome (hazard ratio [HR], 1.07; 95%
confidence interval [CI], 1.03–1.10, P < 0.01). Conclusions: Adverse aortic arch anato-
mies are frequently encountered in CAS procedures and are associated to longer pro-
cedural times. A longer CMT increases the risk for adverse outcome. These data
suggest that a careful procedure planning aimed at a reduction of CMT may be pivotal
to improve the safety of CAS procedures. VC 2015 Wiley Periodicals, Inc.

Key words: carotid artery stenting; aortic arch anatomy; periprocedural stroke

INTRODUCTION of carotid surgery in preventing ipsilateral stroke at

Surgical carotid endarterectomy represents the gold
standard to prevent ischemic stroke in both asymptom-
atic and symptomatic patients with internal carotid
artery (ICA) stenosis [1]. Carotid artery stenting
(CAS), after the development of crush-resistant stents
and embolic protection devices, has been demonstrated
to represent a valuable alternative option for ICA re-
vascularization [2–4]. In addition, a large group of
randomized studies showed that CAS with embolic
protection is at least not inferior to carotid endoarterec-
tomy among patients with severe ICA and high surgi-
cal risk [3,5]. Looking critically at clinical results
obtained with CAS, a series of observations raised the
issue that CAS, as compared with carotid surgery, may
be associated with higher 30-day rates of cerebrovascu-
lar events [6–8]. However, these studies showed a large
interoperator variability in reaching the expected learn-
ing curve, so that their effectiveness in current practice
is still questionable. In addition, a large number of
studies showed that CAS has at least the same efficacy
midterm follow-up [3,4,9,10]. Thus, the prediction and
possibly the prevention of periprocedural cerebrovascu-
lar events is a critical aspect of CAS implementation.
Cardiovascular Sciences Department, Institute of Cardiology,
Catholic University of the Sacred Heart, Rome, Italy
Conflict of interest: Nothing to report.
*Correspondence to: Francesco Burzotta, MD, PhD, Institute of Car-
diology, Catholic University of the Sacred Heart, L.go Gemelli 8,
Rome 00168. E-mail: f.burzotta@rm.unicatt.it
This article was published online on 02 April 2015. An error was sub-
sequently identified. This notice is included in the online and print
versions to indicate that both have been corrected [09 April 2015].
Received 17 November 2014; Revision accepted 14 March 2015
DOI: 10.1002/ccd.25947
Published online 2 April 2015 in Wiley Online Library
(wileyonlinelibrary.com)

C 2015 Wiley Periodicals, Inc.

V

Aortic arch anatomy may deeply influence CAS pro-
cedures but various types and definitions of variants
have been previously applied. In this study, we sought
to establish the procedural and clinical impact of aortic
arch elongation variants and bovine variants on CAS
procedures performed with distal or proximal neuropro-
tection.
METHODS
Study Population
The study population comprised consecutive patients
who underwent CAS in the cath lab of our Institution.
Patients with documented or suspected heart disease
were submitted to CAS when an asymptomatic ICA
stenosis of 80% or a symptomatic stenosis of 50%
was found by Echo–Doppler ultrasonography. The
patients were considered symptomatic if they had evi-
dence of an ipsilateral transient ischemic attack (TIA)
or stroke within the previous 6 months [11,12]. Major
exclusion criteria were as follows: ischemic stroke
within the previous 48 hours, recent cerebral hemor-
rhage, total occlusion of the target vessel, bleeding or
coagulative disorder, contraindication for antithrombotic
therapy, life expectancy of <1 year, and confirmed
allergy to contrast agent, aspirin, or clopidogrel. Accord-
ing to an internal operative protocol aimed at reducing
the risk of renal damage, all patients received before
CAS an head CT scan without contrast dye and carotid/
aorta angio–CT scan was not routinely performed.
The study conformed to the Declaration of Helsinki
and patients gave written informed consent to the pro-
cedure.
Revascularization Procedure
All patients were on dual antiplatelet therapy (aspirin
100 mg and clopidogrel 75 mg/day) since at least 3
days before the intervention and until 4 weeks after.
All procedures were performed by two experienced
interventional cardiologists who previously received a
dedicated and proctored training for peripheral and ca-
rotid interventions.
Revascularization procedures were performed
through transfemoral (in the majority of patients) or
transradial approach under local anesthesia, with sys-
temic heparinization and 6F-10F introducers (Terumo,
Tokyo, Japan). As CT–angio scan was not routinely per-
formed before the procedure, aortic arch digital subtrac-
tion angiography was systematically performed with
10 mL of contrast media to evaluate anatomical variants
and to plan the most suitable carotid access technique.
Routine cerebral protection was attempted by a prox-
imal or distal filter embolic protection device. During
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Aortic Arch Variants in CAS 481
the early study period, distal filter protection was sys-
tematically adopted and proximal protection was
selected for the patients considered at high risk only.
During a second period, proximal protection was sys-
tematically adopted and distal filter protection has been
used only for patients with in-stent restenosis as a target
lesion, with significant common carotid artery (CCA)
disease and with external carotid artery occlusion.
CAS under distal filter protection was performed
using a guiding catheter technique and using, according
to lesion morphology and operator’s discretion, the Fil-
ter EZ (Boston Scientific, Natick, MA), the Spider
(EV3), or the Accunet (Abbott Vascular, Abbott Park,
IL) filter device. Guiding catheter selection was per-
formed according to the aortic arch anatomy. In partic-
ular, according to our clinical practice, 40-XF catheter
(Cordis, Warren, NJ) was selected for type I and II
aortic arches, whereas Hockey stick guiding catheters
(Cordis, Warren, NJ) were used for type III arches or
left carotid procedures in patients with bovine arches.
Finally, anytime guiding catheter cannulation was con-
sidered not stable, a 0.01400 Choice extra-support
guidewire (Boston Scientific) was usually positioned
into the common carotid artery as a “buddy wire” to
stabilize the system before attempting filter protection.
CAS under proximal protection was performed using
the 8F or 9F MoMa (Invatec Medtronic, Roncadelle,
Italy) proximal protection device. According to our tech-
nique for transfemoral MOMA procedures, a diagnostic
JR 4 5F catheter (Cordis, Warren, NJ) and a 0.0350 soft
hydrophilic wire (Terumo) were used routinely to can-
nulate the CCA and then, after angiography and road-
mapping, to reach the external carotid artery. In patients
with type III aortic arch or with acute-angled left caro-
tids arising from bovine arches, IM 5F (Cordis, Warren,
NJ) or 3DRCA (Cordis, Warren, NJ) diagnostic catheter
was selected. After the 5F diagnostic catheter reached
the external carotid artery, a 0.0350 extra-stiff wire
(Supracore, Abbott Vascular, Abbott Park, IL) was
advanced and used to support MOMA delivery.
Right radial access was electively selected for left
ICA–CAS in the few cases where the existence of a
bovine arch anatomic variant was known before the
procedure. In the remaining cases, femoral approach
was systematically adopted as a first access.
The 8F MoMa device was selected for transradial
procedures (the technique for transradial MoMa has
been described previously [13]), whereas 9F MoMa
was generally selected for transfemoral procedures
(usually, with 10F sheath to keep blood pressure moni-
toring through the sheath’s side-line during the endo-
clamping phase).
After positioning of the protection device, self-
expandable stents were implanted with or without
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
482 Burzotta et al.
Fig. 1. The samples of patients with type I (A), type II (B), and type III (C) aortic elongation
variants.
balloon predilation and postdilation was performed
with large (usually, 5  20 mm) coronary balloons.
Carotid stent type was selected at operator’s discretion,
trying to select the best matching between stent type
and carotid anatomy [14]. Procedural success was
defined as successful ICA stenting under proximal or
distal neuroprotection with the achievement of residual
visual stenosis of <30%. Clinical failure was defined
as the occurrence of death or cerebrovascular accident
during the index hospitalization.
Catheter manipulation time (CMT) was defined as
the time interval between the first angiogram depict-
ing aortic arch and the procedure end. It is worth not-
ing that as lot of patients received coronary or
peripheral diagnostic angiography during the CAS pro-
cedure to ascertain the presence of coronary artery
disease or to plan peripheral interventions, whole pro-
cedure length and contrast volume were not assessed
in this study.
Aortic Arch Anatomic Variants
Aortic arch elongation variants and bovine arch var-
iants were prospectively gathered before carotid inter-
vention beginning by aortic arch digital subtraction
angiography.
Aortic arch elongation variants were classified
according to the vertical distance from the origin of
the innominate artery to the top of the arch (Fig. 1)
[15]:
Type I arch, if the distance was <1 diameter of the
left CCA;
Type II arch, if the distance was between 1 and 2
left CCA diameters;
Type III arch, if the distance was >2 left CCA
diameters.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Bovine arch variants were defined as follows (Fig. 2)
[16]:
Bovine I: common origin of innominate artery and
left CCA (Fig. 2A);
Bovine II: origin of the left CCA from the innomi-
nate artery (Fig. 2B).
Clinical Outcome Assessment
All patients underwent clinical evaluation prior to
CAS and were monitored in the hospital for at least 48
hours. During hospitalization, in the case of any sus-
pect of neurological symptom, a neurological evalua-
tion was performed on urgent basis by the neurologists
of the Stroke Unit of our hospital who were responsi-
ble for the diagnostic and therapeutic management. In
patients with suspected neurological symptoms occur-
ring during hospitalization, the final adjudication of a
neurological complication was performed on the basis
of the neurologists’ evaluation as recorded in the offi-
cial medical records. After discharge, 30-day patients’
outcome was assessed by ambulatory visit or phone
contact or, in the case of hospital readmission, by the
revision of official medical records. It is worth noting
that asymptomatic patients did not undergo systematic
neurological examination.
TIA was defined as focal brain ischemia with the re-
solution of symptoms within 24 hr after onset. Stroke
was defined as a new neurological deficit of sudden
onset with symptoms and signs consistent with focal is-
chemia lasting at least 24 hr in the absence of primary
hemorrhage, which was not explained by other causes
(e.g., cardiac embolism, trauma, infection, or vasculi-
tis). Stroke was considered minor if neurological defi-
cit resolved completely within 30 days or did not lead
 Aortic Arch Variants in CAS 483

Fig. 2. The samples of patients with type I (A) and type II (B) bovine anatomy aortic variants.

to an impairment in daily activities, otherwise it was TABLE I. Main Clinical Characteristics of Our Study Popula-
considered as major. Major neurological events tion
included fatal or nonfatal major stroke. Minor neuro- Overall (n ¼ 282)
logical events comprised TIA and minor stroke. Myo- Age (years) 72  7
cardial infarction was defined as rise and fall of Female gender n (%) 77 (27.3)
cardiac biomarker values with at least one value above Risk factors
the 99th percentile of the upper reference limit com- Diabetes mellitus, n (%) 52 (18.4)
bined with ischaemic chest pain or electrocardiographic Current smoker, n (%) 40 (14.2)
Hypercholesterolemia, n (%) 163 (57.8)
evidence of ischemia or imaging evidence of new loss Hypertension, n (%) 201 (71.3)
of viable myocardium/new regional wall motion abnor- Family history of CAD, n (%) 58 (20.6)
mality or identification of an intracoronary thrombus Renal failure, n (%) 50 (17.7)
by angiography [17]. Cardiovascular history
Neurological symptoms, n (%) 20 (7.1)
Significant CAD, n (%) 123 (43.6)
Statistical Analysis Prior AMI, n (%) 29 (10.3)
Categorical variables were presented as numbers and Prior PCI, n (%) 57 (20.2)
Prior CABG, n (%) 47 (16.7)
percentages and analyzed with Fisher’s exact test. The Angiographic characteristics
comparisons of continuous variables among the three Left ICA as target vessel, n (%) 123 (43.6)
groups were performed by one-way ANOVA. Stepwise Complex lesion (ulcerated/irregular 69 (24.5)
forward logistic regression was used to examine the inde- boarder), n (%)
pendent association between complications and each Aortic arch anatomic variants
Type I 184 (65.2)
potential determinant. Predicting variables were included Type II 66 (23.4)
in the multivariate model because of clinical relevance in Type III 32 (11.4)
the presence of a univariate association P-value of <0.2. Bovine I (common origin of 41 (14.5)
A P-value of <0.05 was considered statistically sig- innominate artery and left CCA)
nificant. Statistical analysis was performed using SPSS Bovine II (origin of the left CCA 17 (6.0)
from the innominate artery)
20.0 (SPSS, Chicago, IL).
Abbreviations: AMI, acute myocardial infarction; CAD, coronary artery
disease; CABG, coronary artery bypass graft; CCA, common carotid ar-
RESULTS tery; n, number of patients; ICA, internal carotid artery; PCI, percutane-
ous coronary intervention.
Characteristics of the Study Population and CAS
Procedure Details The clinical characteristics of enrolled patients are
A total of 282 patients (age, 72  7 years; 72.7% summarized in Table I. Most of the patients had his-
males) undergoing CAS were included in the study. tory of coronary artery disease or documented coronary
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
484 Burzotta et al.
artery stenoses or previous history of myocardial in-
farction or myocardial revascularization.
The characteristics of CAS procedures are summar-
ized in Table II. Procedural failure occurred in two
(0.7%) patients: in both cases, the operators decided to
refrain from proceeding with the attempt to treat the
ICA lesion after having encountered major difficulties
in safely placing the planned neuroprotection device
owing to adverse anatomy (an asymptomatic patient
with type I aortic arch and severe proximal tortuosities,
a symptomatic patient with type I aortic arch and
severe atherosclerosis of CCA which was considered
unsuitable for the intended proximal protection). Both
patients were then referred for elective surgical carotid
revascularization. All remaining procedures were suc-
cessfully completed under cerebral protection device.
Among patients in which MOMA protection was
attempted, five (3.1%) showed a serious hemodynamic
intolerance to the device so that crossover to distal fil-
ter protection (deployed through the MOMA device)
was required to complete the procedure. The stenting
technique and the stent types are listed in Table II.
Patients with “clinical failure,” compared to those
with nonclinical event, exhibited a significantly higher
CMT (55.1  16.5 vs. 39.5  12.9 min, respectively;
P < 0.01).
Only two patients (0.7%) had an access-site vascular
complication (one patient reported femoral pseudoan-
eurysm solved by echo-guided manual compression
and one patient, treated with femoral nonsuture closure
device hemostasis, required urgent surgery owing to
postprocedural common femoral artery thrombosis).
It is worth noting that CMT was not significantly
different between CAS procedures with distal filter
protection or proximal protection (38.8  13.8 vs.
41.3  13.1 min, respectively; P ¼ 0.13).
Aortic Arch Elongation Variants and Procedure
Duration
Aortic arch elongation variants noticed by pre-CAS
angiography are listed in Table I. It is worth noting
that type II or III variants were observed in as many as
98 patients (34.8%). Among all the pre-PCI demo-
graphic and clinical characteristics, only age was sig-
nificantly associated with aortic arch elongation
(P < 0.001).
Mean CMT in the whole population was 40.2  13.5
min. CMT was significantly different between patients
with type I, type II, and type III aortic arch
(P < 0.0001, Fig. 3).
To evaluate the possible different impacts of aortic
elongation variants in procedures conducted with dif-
ferent types of neuroprotection, CMT was analyzed
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
according to aortic arch variants in patients with distal
or proximal protection. As shown in Fig. 3, CMT was
still significantly different among the three elongation
groups even when separately considering patients who
underwent proximal MOMA protection (P < 0.001) or
those with distal filter protection (P < 0.001).
Bovine Aortic Arch Variants and CMT
In the whole population, bovine aortic arch was
present in 58 cases (20.5%): 41 (14.5%) patients had a
bovine I arch, whereas 17 (6.0%) patients had a bovine
II arch (Table I). As the presence of bovine aortic arch
variants may influence left ICA–CAS procedures only,
the impact of them was explored in this subgroup of
patients. In patients with left ICA disease (n ¼ 123,
43.6%), the presence of bovine arch variants was asso-
ciated with a significantly higher CMT compared to
the patients with nonbovine anatomy (49.2  11.4 vs.
37.7  11.5 min, respectively; P < 0.001). It is worth
noting that the impact of bovine arch was similar
between the patients undergoing CAS with distal filter
protection or proximal protection (Fig. 4). Finally, the
right radial approach (within the limitation of the small
numbers of observations) showed a possible favorable
impact on the management of patients with bovine
arches undergoing left ICA–CAS as CMT was not sig-
nificantly different between bovine and nonbovine
anatomies in patients approached by radial access (Fig.
5).
Predictors of Clinical Outcome
Thirty-day clinical follow-up was obtained for all
patients enrolled in the study. At 30-day, we noticed
one death (0.3%) owing to the respiratory complication
of a major intraprocedural stroke (fatal stroke) and four
major nonfatal strokes (1.4%). Minor stroke occurred
in six patients (2.1%) and a TIA in four patients
(1.4%). Out of the 14 major or minor neurological
events, 78% (n ¼ 11) happened during the CAS proce-
dure, whereas the three other were reported within the
first 15 days of follow-up. One patient developed AMI
at 15 days after CAS procedure; he was successfully
treated by percutaneous coronary revascularization.
Adverse events rates are listed in Table III.
Patients with type III aortic arch had a higher inci-
dence of 30-day minor strokes but no difference was
found among the three groups in 30-day cardiac or cer-
ebral events (Table III). Similarly, in patients who
underwent CAS on left ICA, the presence of a bovine
arch anatomy was not associated with significantly
higher complication rates (Table III).
Univariate predictors of 30-day cardiac or cerebral
events are summarized in Table IV. Patients who
 Aortic Arch Variants in CAS 485

TABLE II. Main Procedural Characteristics of Our Population Undergoing CAS

Overall n ¼ 282 Type I n ¼ 184 Type II n ¼ 66 Type III n ¼ 32 P-value
Vascular access
Femoral 265 (94.0) 177 (96.2) 56 (84.8) 32 (100) 0.001
Radial 17 (6.0) 7 (3.8) 10 (15.2) 0 (0)
Access crossover 2 (0.7) 0 2 (3.0) 0 0.04
Neuroprotection
Distal filter protection (%) 119 (42.2) 82 (44.6) 24 (36.4) 13 (40.6) 0.50
Proximal protection (MOMA) (%)a 163 (57.8) 102 (55.4) 42 (63.6) 19 (59.4)
Balloon predilation 67 (23.8) 48 (26.1) 13 (19.7) 6 (18.7) 0.45
Carotid stent type
Open cellb 93 (33.0) 68 (36.9) 17 (25.7) 8 (25.0) 0.15
Closed cellc 95 (33.7) 59 (32.1) 23 (34.8) 13 (40.6) 0.64
Hybrid stentd 87 (30.8) 52 (28.3) 25 (37.9) 10 (31.2) 0.35
Procedural success 2 (0.7) 2 (1.0) 0 (0) 0 (0) 0.59
Clinical failure 13 (4.6) 7 (3.8) 5 (7.6) 1 (3.3) 0.42
a
Including five patients who developed severe MOMA intolerance and had to switch to filter use.
b
Acculink (Abbott Vascular).
c
Wallstent (Boston Scientific).
d
Cristallo Ideale (Invatec Medtronic).

Fig. 3. CMT according to aortic elongation variants in the whole study population (A) and in
the subgroups undergoing proximal or distal neuroprotection (B).

developed an event were significantly older than those
with no neurological or vascular event at follow-up
(77.1  6.2 vs. 72.3  7.4 years, respectively; P ¼ 0.01).
In addition, patients with a 30-day cardiac or cerebral
event had a significantly higher CMT than those with
no events at follow-up (57.4  19.1 vs. 39.3  12.4 min,
respectively; P < 0.001). At multivariate analysis, CMT
was the only independent predictor of 30-day cerebro-
vascular accidents (multivariate hazard ratio [HR], 1.07;
95% confidence interval [CI], 1.03–1.10; P < 0.01).
DISCUSSION
CAS is increasingly carried out to treat the patients
with ICA stenosis but its feasibility may be influenced
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
by a series of patient’s features including the aortic
arch anatomy. In this study, we investigated the clini-
cal and procedural impact of common aortic arch ana-
tomic variants in CAS conducted with distal or
proximal neuroprotection. The main findings are that:
1. CAS with either distal or proximal neuroprotection
is feasible in patients with various aortic arch var-
iants.
2. CMT during CAS procedure is significantly influ-
enced by the aortic arch elongation or (in the case
of left CAS) bovine arch variants.
3. CMT, but not the presence of aortic arch variants, is
significantly associated with adverse clinical out-
come.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
486 Burzotta et al.

Fig. 4. CMT according to bovine anatomy variants in patients who underwent CAS on left
ICA (A) and in those undergoing proximal or distal neuroprotection (B).

Fig. 5. CMT according to bovine anatomy variants and type of access (radial vs. femoral) in
patients who underwent CAS on left ICA.

TABLE III. Thirty-Day Adverse Events in the Whole Population and According to Aortic Arch Elongation or Bovine Variants
Overall Type I Type II Type III P- Left ICA Nonbovine Bovine P-
n ¼ 282 n ¼ 184 n ¼ 66 n ¼ 32 value n ¼ 123 n ¼ 91 n ¼ 32 value
Major cerebral events (%) 4 (1.4) 3 (1.6) 1 (1.5) 0 (0) 0.77 2 (1.6) 2 (2.2) 0 (0) 0.40
Death (%) 1 (0.3) 1 (0.5) 0 (0) 0 (0) 0.77 0 (0) 0 (0) 0 (0) –
Nonfatal major stroke (%) 3 (1.1) 2 (1.1) 1 (1.5) 0 (0) 0.79 2 (1.6) 2 (2.2) 0 (0) 0.40
Minor cerebral events (%) 10 (3.5) 4 (2.2) 5 (7.6) 1 (3.1) 0.12 5 (4.1) 3 (3.3) 2 (6.2) 0.60
Minor stroke (%) 6 (2.1) 2 (1.1) 4 (6.1) 0 (0) 0.03 3 (2.4) 1 (1.1) 2 (6.2) 0.10
TIA (%) 4 (1.4) 2 (1.1) 1 (1.5) 1 (3.1) 0.66 2 (1.6) 2 (2.2) 0 (0) 0.40
Myocardial infarction (%) 1 (0.3) 1 (0.5) 0 (0) 0 (0) 0.77 1 (0.8) 0 (0) 1 (3.1) 0.09
Any cardiac or cerebral event (%) 15 (5.3) 8 (4.3) 6 (9.1) 1 (3.1) 0.26 8 (6.5) 5 (5.5) 3 (9.4) 0.44
Abbreviations: ICA, internal carotid artery; TIA, transient ischemic attack.

Taken together, these data suggest that careful pro- gain of a stable CCA cannulation. Previous studies
cedure planning aimed at minimizing the impact of reported for adverse anatomic variants (defined in dif-
aortic arch variants on CMT may be pivotal to improve ferent ways and with different scores) an overall
the safety of CAS procedures. increased risk of procedural failure and neurological
The aortic arch anatomy represents a major modula- complications in the course of CAS [18–23]. These
tor of CAS procedural complexity as it influences the studies, however, were focused on CAS procedures
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

TABLE IV. Univariate and Multivariate Predictors of the Combined End-Point of Any Cardiac or Cerebral Event at 30 Days
Univariate HR (95% CI)
Age 1.11 (1.02–1.12)
CMT 1.06 (1.03–1.10)
Diabetes 2.34 (0.76–7.16)
Hypertension 2.73 (0.60–12.38)
Dyslipidemia 1.49 (0.50–4.48)
Symptoms 3.68 (0.95–14.28)
Complex plaque 0.76 (0.21–2.78)
Type III arch 0.54 (0.07–4.28)
Open cell stent 0.73 (0.22–2.35)
Proximal protection 0.47 (0.16–1.35)
Bovine arch 2.02 (0.66–6.16)
Abbreviation: CMT, catheter manipulation time.
conducted mainly with distal protection and do not
assess quantitatively any parameter measuring proce-
dural complexity. In this study, we prospectively inves-
tigated the aortic morphology by systematic pre-CAS
digital subtraction angiography and classified aortic
anatomy using established elongation grading and bo-
vine configurations. We have confirmed the high prev-
alence of adverse aortic features as testified by a
23.4% of type II and 11.3% of type III aortic arch
variants. Such figures are slightly higher than the pre-
viously reported literature [24,25], probably owing to
the absence of any preprocedural screening and to the
older age of our study population. The latter hypothesis
is supported by the fact that, among all the pre-CAS
demographic and clinical characteristics, age was the
only parameter significantly associated with aortic arch
elongation.
In contrast with some previous studies, we have
been able to show that CAS is feasible in a variable
spectrum of aortic arch abnormality (only 2 failures
out of 282 cases). Such high success rates fit with
those of recent high-volume centers’ experience
[26,27] and are probably owing to a careful procedure
planning which was “tailored” to manage the individ-
ual aortic anatomy [14].
In the presence of low rate of failures, procedure
complexity may be measured by the parameters esti-
mating resource consumption. Among these, the pa-
rameter which is theoretically more relevant for CAS
safety is the duration of catheter manipulation. Thus,
in this study, we decided to use “CMT”: a novel easy-
to-measure time interval. The observed results show
that procedure complexity, as measured by CMT, dif-
fers according to arch elongation variants as well as (in
left ICA––CAS) to bovine configurations. It is worth
noting that the neuroprotection strategy did not affect
the impact of aortic arch variants as CMT was similar
in patients undergoing distal or proximal neuroprotec-
tion, whereas CMT differed significantly according to
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Aortic Arch Variants in CAS 487
P-value Multivariate HR (95% CI) P-value
0.02 1.08 (0.99–1.18) 0.09
<0.01 1.07 (1.03–1.10) <0.01
0.14 2.34 (0.65–8.43) 0.19
0.19 1.22 (0.24–6.29) 0.81
0.48
0.06 3.23 (0.66–15.93) 0.15
0.68
0.56
0.59
0.16 0.37 (0.11–1.25) 0.11
0.22
aortic elongation or bovine variants in both CAS with
proximal and distal neuroprotection. It should be noted
that, in the case of left ICA–CAS in patients with
known bovine arch anatomies, a right-arm approach (in
our series, via radial access) may be considered to
shorten the operative times.
Finally, we found that CMT but not complex anat-
omy features was independently associated with 30-day
clinical outcome. Such finding supports the notion that
catheter manipulation during CAS procedures is a main
technical modulator of clinical outcomes and calls for
careful procedure planning. Indeed, other anatomical
aspects may concur with aortic arch anatomy to deter-
mine the overall procedure complexity. In particular,
factors such as vessel tortuosities and aortic atheroscle-
rosis which have not systematically been assessed in
this study may play a role in hindering the completion
of smooth CAS procedures and may not be easily diag-
nosed by a simple digital subtraction angiography.
Accordingly, the possible clinical relevance of a com-
prehensive pre-CAS risk stratification by noninvasive
radiologic imaging should not be underestimated [28].
Study Limitations
This study reflects a single-center experience so that
the observations have the limit of stemming from a re-
stricted number of operators with similar experience.
In particular, it should be emphasized that we did not
adopt dedicated carotid catheters and such catheters
have been recently shown to facilitate procedure com-
pletion in the case of hostile aortic arch anatomies
[29].
No systematic neurological examination has been
performed after discharge in patients who reported to
be asymptomatic. As a consequence, the possibility of
event underreporting cannot be ruled out. Yet, as all
patients who developed suspected neurological symp-
toms during hospitalization had a full neurologic
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
488 Burzotta et al.
clinical evaluation, only minor cerebrovascular acci-
dents occurring after discharge may have been undiag-
nosed.
CONCLUSIONS
CAS is a safe and effective therapeutic option to
treat carotid artery disease. Among procedural factors
capable of predicting clinical outcome, the presence of
unfavorable arch anatomies has a relevant weight in
determining periprocedural outcome. In our study, we
showed that CAS is feasible, even by using proximal
or distal neuroprotection, independently of aortic arch
anatomy.
The presence of aortic arch elongation or bovine
arch variants significantly increased procedural time, as
assessed by CMT, in our population. However, we
found that CMT, but not the presence of aortic arch
variants, is significantly associated with 30-day adverse
clinical outcome, thus suggesting that a careful plan-
ning of the procedure by well-trained operators, aiming
at reducing CMT in the aortic arch, could be helpful in
improving clinical outcome even in patients with
adverse anatomies.
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