Novel Use Of Trans-carotid Revascularization System For Brachiocephalic Vascular Interventions

Abstract

<h3>OBJECTIVE</h3> As the experience with trans-carotid artery revascularization (TCAR) is expanding, its applicability of TCAR in patients with the more complex brachiocephalic disease has not been described. We examined our experience with TCAR used in combination with other cerebrovascular interventions including retrograde common carotid artery (CCA) stenting and carotid-subclavian bypass. <h3>METHODS</h3> We included patients with significant ICA stenosis amenable to TCAR but also with concomitant hemodynamically significant and clinically significant common carotid or subclavian artery stenosis over a 2 year period. All patients had a supra-clavicular incision with exposure to the CCA. In patients with subclavian stenosis, the carotid-subclavian bypass was performed first (8mm Dacron) and the graft was accessed using the TCAR system for the ICA intervention. In patients with common carotid stenosis, the common carotid was accessed retrograde using the cerebral protection system, and the intervention was performed. Then the TCAR system was converted to antegrade and ICA intervention was completed. All cases were performed under general anesthesia. Cerebral protection (passive or active) and neuromonitoring were used during all procedures. <h3>RESULTS</h3> 71 patients underwent TCAR, and of these, 8.5% (n=6) underwent combined procedures. Two patients had concomitant CCA stenosis and four patients with subclavian artery stenosis. One patient had an occluded contralateral ICA. No patients in the combined group had postoperative complications (stroke or myocardial infarction or cranial nerve injury) and all were discharged home on a postoperative day one. Table 1 summarizes the outcomes for the study population. <h3>CONCLUSION</h3> The novel use of the cerebral protection system for proximal intervention, or incorporating the TCAR system in a hybrid approach to complex brachiocephalic disease is effective in providing safe, comprehensive treatment solutions.