Transcarotid Artery Revascularization by Prosthetic Conduit for Patients With Unfavorable Common Carotid Anatomy

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Transcarotid artery revascularization (TCAR) using the ENROUTE Transcarotid Neuroprotection and Stent System (Silk Road Medical, Sunnyvale, Calif) is a hybrid technique with excellent initial outcomes. The technical success of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet the anatomic criteria for TCAR and are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy by the adoption of a prosthetic arterial conduit. Patient 1, a 57-year-old man, presented with recurrent >90% internal carotid artery (ICA) stenosis after carotid endarterectomy for symptomatic disease. Arteriography demonstrated severe stenosis of the ICA and diffuse CCA atherosclerosis (Fig, A). The CCA was replaced with a 6-mm polytetrafluoroethylene interposition graft incorporating a side arm limb for stent deployment (Fig, B-D). Patient 2 was a 62-year-old man with prior neck irradiation and asymptomatic >90% stenosis of the distal CCA. Computed tomography angiography showed a <5-cm distance from clavicle to carotid lesion. We performed TCAR by a 6-mm Dacron conduit sewn to the CCA. Patient 3 was an 80-year-old woman with recurrent symptomatic >80% ICA stenosis. TCAR was performed in the same manner as in patient 2, secondary to short distance. Patient 4, a 65-year-old man with prior neck irradiation and ICA stent, presented with severe in-stent stenosis and distal CCA stenosis. TCAR was performed by a Dacron conduit sewn to the proximal CCA with stenting of both ICA and CCA lesions. Technical success was 100% (Table). The 30-day ipsilateral stroke rate was 0%; however, the 30-day patency was 75%. Patient 2 experienced anaphylaxis after protamine administration and a subsequent cardiac arrest. He recovered without consequence. Computed tomography angiography 1 month postoperatively demonstrated stent thrombosis. TCAR is an excellent option for many patients with carotid artery stenosis. Unfavorable CCA anatomy has limited the applicability of this hybrid technology. TCAR by a prosthetic conduit has the potential to expand the eligibility for this promising therapy.TableResultsProcedure time2 hoursFlow reversal time8.5 minutesTechnical success100%30-day patency75%30-day stroke0% Open table in a new tab