Transcervical Carotid Artery Stenting With Conduit and Flow Reversal: Pushing the Transcarotid Envelope

Abstract

The transcervical approach to carotid artery stenting (TCAR) has demonstrated lower periprocedural stroke risk compared to transfemoral access, particularly when using the flow reversal technique. The indications for use of the existing system limit its safe application in cases with unfavorable neck anatomy where the carotid bifurcation is less than 5 cm above the clavicle. We present our initial experience with five patients who underwent TCAR using an adjunctive prosthetic conduit technique augmented with flow reversal. The common carotid artery (CCA) was exposed and a 6-mm transcervical polytetrafluoroethylene conduit was sutured to the proximal CCA and brought out to the anterior chest wall (Figure). This created a long, sTable platform accessible to the conventional TCAR platform. The conduit also allowed for improved control and pushability in short common carotid arteries and difficult internal carotid lesions. Flow reversal was employed via access of the common femoral vein, and each patient was stented without technical complication. The conduit was suture ligated at the CCA with a small stump of prosthetic material left in place. All patients had an American Society of Anesthesiology score of 3. The indication for three of the five cases was asymptomatic restenosis following previous carotid endarterectomy with the other two cases involving symptomatic stenosis in reoperative or previously radiated necks. All procedures were performed under local with sedation with successful deployment of stents and resolution of the stenosis on completion angiogram and postoperative duplex scan. Average operative time was 2 hours and 16 minutes. All patients were discharged home with a less than 48-hour stay. Demographic, procedural, and outcomes information is presented in the Table. There were no periprocedural strokes or mortality. All patients recovered from their procedure without incident and are free from restenosis, major adverse cardiovascular events, or nerve injuries at a median of 7.6 months of follow-up (range 1.5-11.4 months). Transcervical carotid artery stenting with flow reversal via arterial conduit is a safe and feasible technique. This simple modification to existing embolic protection strategies expands the number of patients who are candidates for TCAR and presents an excellent option in patients with complex and challenging cervical and aortic arch anatomy.TableDemographic, procedural, and outcomes informationCase no.Age, yearsSexSide and stenosisOperative indicationComorbidities a and HistoryComplicating factor(s)Operative timeSurveillance, monthsComplications163FLeft80%-99%Asymptomatic RestenosisHTN, AS, obesity, Hx left CEAShort CCA, reoperative, hostile arch1' 45"11None276MLeft <70% (w/ ulcer)Symptomatic CCA ulcerHTN, AFib, Hx CABG, CVA, Hx left CEAShort CCA, hostile arch, reoperative, cardiac risk1' 46"10None386FLeft80%-89%Asymptomatic restenosisHTN, Hx PCI, Hx left CEAShort CCA, hostile arch, reoperative2' 01"5None463MRight80%-99%Symptomatic StenosisHx non-Hodgkins Lymphoma and neck radiationCCA stenosis, irradiated field, contrast allergy, tortuous CCA3' 48" (converted from initial transfemoral access)8Seroma, reoperation at 8 weeks postoperative570FLeft80%-89%Asymptomatic RestenosisHTN, Diabetes, Hx PCI, COPD, chronic kidney disease, Hx Bilateral CEAShort CCA, reoperative2' 00"1.5NoneAFib, Atrial fibrillation; AS, CABG, coronary artery bypass grafting; CCA, common carotid artery; CEA, carotid endarterectomy; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; F, female; HTN, hypertension; Hx, history; M, male; PCI, percutaneous coronary intervention. Open table in a new tab