Innovative left internal carotid stenting via right brachial access in a high-risk patient

Carotid artery stenosis in patients with complex comorbidities, severe calcification, and prior surgical interventions presents significant procedural challenges. Traditional access routes for stenting, such as transfemoral or transcarotid, may be unfeasible in such cases, requiring innovative alternatives. A 79-year-old man with symptomatic high-grade left internal carotid artery stenosis, severe aortoiliac occlusive disease, and a history of failed transfemoral stenting was treated successfully with left internal carotid artery stenting via right brachial artery access. The patient's complex vascular anatomy, including a bovine arch, calcified carotid bifurcation, and postradiation fibrosis, made conventional approaches impractical. Shockwave intravascular lithotripsy and embolic protection device were used to modify calcified plaque and prevent embolization. This case demonstrates that right brachial artery access provides a viable and innovative solution for carotid artery stenting in high-risk patients with challenging vascular anatomy. When traditional access routes are contraindicated, this approach expands treatment options, offering a safe and effective alternative for complex carotid interventions.