Open retrograde carotid artery stenting with balloon guiding catheter under local anesthesia for common carotid artery origin stenosis: illustrative case

BACKGROUND: Common carotid artery (CCA) origin stenosis is uncommon, and optimal management remains uncertain, particularly in patients for whom general anesthesia places them at high risk. OBSERVATIONS: A 77-year-old man with interstitial pneumonia presented with acute ischemic stroke due to left M1 occlusion (National Institutes of Health Stroke Scale score 18). Emergency mechanical thrombectomy achieved complete reperfusion (thrombolysis in cerebral infarction score 3) with rapid neurological improvement. Workup identified symptomatic moderate stenosis at the left CCA origin. General anesthesia was deemed high risk due to interstitial pneumonia. The authors performed open retrograde carotid artery stenting (CAS) under local anesthesia with dexmedetomidine. Through a limited cervical cut-down, the CCA was exposed and directly punctured. An 8-Fr balloon guiding catheter (BGC) was inserted sheathless using a purse-string suture for hemostasis. After lesion crossing, predilatation and deployment of a resheathable Carotid Wallstent were performed. Distal embolic protection was achieved by inflating the BGC in the distal CCA with repeated manual aspiration. Final angiography showed adequate expansion without distal embolization. CT angiography on postoperative day 7 confirmed stent patency. LESSONS: Open retrograde CAS under local anesthesia could be a feasible option for CCA origin stenosis in patients at elevated anesthetic risk. A sheathless BGC could permit reliable distal protection, securing hemostasis with limited exposure. https://thejns.org/doi/10.3171/CASE25917.