Transcervical Access Research Articles

Single-Port da Vinci Robot-Assisted Cervical Esophagectomy: How to Do It.

Minimally invasive esophagectomies, including robot-assisted procedures, have demonstrated superiority over traditional open surgery. Despite the prevalence of transhiatal and transthoracic approaches, cervical access is less common in minimally invasive esophageal surgery. Advancements in robotic systems, such as the da Vinci Single Port (SP), enable controlled transcervical extrapleural mediastinoscopic access, potentially reducing pulmonary complications and extending surgical options to patients with comorbidities. The da Vinci SP robot-assisted cervical esophagectomy (SP-RACE) employs an SP and laparoscopic approach, demonstrating feasibility with comparable lymphadenectomy and recurrent nerve palsy rates to transthoracic methods. This technique, performed for the first time in Europe at the University Hospital Mainz, involves a transcervical SP phase that allows for effective mediastinal dissection and esophageal mobilization. Despite technical challenges due to limited space, robotic systems enhance controlled access and eliminate arm collision. The da Vinci SP platform's advantages include improved triangulation, fewer interferences, and better control of instruments in confined spaces. This novel approach shows promise for patients with high esophageal tumors and those unsuitable for transthoracic surgery, warranting further investigation into its clinical utility and reproducibility.

Next-generation transcarotid artery revascularization: TransCarotid flOw Reversal Cerebral Protection And CGUARD MicroNET-Covered Embolic Prevention Stent System To Reduce Strokes - TOPGUARD Study.

Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated. We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism. One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler. Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).

Minimally Invasive Treatment of Chyle Leak After Thyroidectomy and Cervical Lymph Node Dissection in Patients with Thyroid Carcinoma: Results of a Study Involving 36 Patients.

Chyle leak (CL) after head and neck surgery is a rare but well-known complication. In patients with high-output leakage, the treatment can be complicated. This study aims to report on a recent innovation in lymphatic intervention for treating such patients. A retrospective review of 36 patients with chyle leak after neck surgery for thyroid cancer was conducted to assess the efficacy of percutaneous lymphatic embolization and thoracic duct (TD) disruption. Antegrade catheterization of the thoracic duct was achieved in 31 of 36 patients (86.1%). Therefore, embolization of the thoracic duct and thoracic duct branches was performed in 26 and 5 patients, respectively. In 5 cases of unsuccessful antegrade catheterization into the thoracic duct, transcervical access embolization was performed in 2 patients, and TD disruption (TDD) was performed in 3 patients. The pooled overall technical success rate of lymphatic embolization was 33/36 patients (91.7%). One patient who underwent thoracic duct embolization (TDE) with technical success (1/33 patients) but clinical failure had additional treatment directly sclerosing the TD under computed tomography scan. Cervical fluid collection sclerotherapy was done in 7 patients as an additional treatment. Resolution of the chyle leak after procedures was observed in all patients (100%). The mean time to resolution was 3 days (1-7 days). There was no complication intra and after procedures. TDE, selective TD branches embolization and TDD are safe and effective minimally invasive treatments for CL post-surgery for thyroid carcinoma. Sclerosing cervical fluid collection contributes to clinical success.

Transcatheter Aortic Valve Implantation Using the Transcervical Vascular Access (from a 7-Year Experience from a Swiss Tertiary Center)

The gold-standard transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is not suitable in 10% to 15% of patients, and alternative accesses are needed. Studies have suggested that the transcervical (TC) access might yield outcomes comparable to the TF access. In our center, TC-TAVI is the first-line alternative to TF-TAVI. We herein present our 7-year experience regarding the use of the TC access in TAVI. We included all consecutive patients referred for TC-TAVI between January 1, 2016 and December 31, 2022. Data regarding the patients' characteristics,perioperative and 30-day outcomes were prospectively collected. Patients were separated into 2 temporal groups (group 1: January 1, 2016 to June 30, 2019; group 2: July 1, 2019 to December 31, 2022) to assess the changes of their characteristics and outcomes over time. A total of 95 patients were included, with more belonging to group 2 (n=56 vs n=39 in group 1). Patients in group 2 were significantly younger (81.0 [interquartile range 77.0 to 87.0] vs 89.0 [interquartile range 83.0 to 92.0] years, p <0.001) and had a higher prevalence of hypertension (87.5% vs 66.7%, p=0.028) and chronic pulmonary disease (35.7% vs 15.4%, p=0.029). There was no significant difference regarding other co-morbidities or surgical scores. All-cause mortality and the risk of stroke at 30days were low and similar (group 2 vs group 1, 3.6% vs 2.5%, p=0.787 and 1.8% vs 0%, p=0.397, respectively), as were the risks of permanent pacemaker implantation, postoperative acute kidney injury, cardiac tamponade, life-threatening bleeding, and major vascular complications. In conclusion, the use of the TC access increased over time. The rates of adverse events did not change, despite patients from mid-2019 onward having slightly more co-morbidities.

From surgical clamping to endovascular flow arrest/reversal: the concept behind the system.

Carotid artery lesions are frequently composed of friable, thrombotic, ulcerated and/or hemorrhagic materials which can embolize during surgical or endovascular interventions. The use of embolic protection devices (EPD) during carotid angioplasty and stenting (CAS) has been proven to be associated with a reduction of the embolic load. Many studies indicate that the clinical results of CAS are comparable with the best surgical series, when EPD are routinely applied. The proximal EPD work by interrupting or reversing the blood flow in the common carotid artery/internal carotid artery (CCA/ICA). Once established the endovascular flow arrest/reversal, these systems have the advantages of promoting a protected crossing of the lesion and blocking both macro-emboli and micro-emboli. Moreover, proximal neuroprotection implies no manipulation of the device in the distal ICA, neither during device deployment nor during device retrieval, and reduces the risk of arterial spasm, dissection, or intimal damage. The choice between transfemoral and transcervical proximal EPD should account for different factors: local availability, operator expertise, and patient characteristics including anatomical features precluding flow arrest/reversal (e.g., incomplete circle of Willis), femoral access (e.g., unfavorable aortic arch anatomy), or transcervical access (e.g., diseased CCA).

Evaluating the Safety of Transcarotid Artery Revascularization under Local Anesthesia Prior to Coronary Artery Bypass Grafting Surgery

Controversy exists regarding the timing of intervention for patients with critical coronary artery disease awaiting coronary artery bypass and severe carotid artery stenosis. Transcarotid artery revascularization (TCAR) is a minimally invasive revascularization alternative through direct transcervical carotid access that minimizes the chance of arch manipulation and consequent antegrade embolic stroke rate. While the TCAR procedure can be performed under local anesthesia (monitored anesthesia care, MAC) vs general anesthesia, the hemodynamic benefits of local anesthesia in patients with severe CAD are significant. Patients receiving staged TCAR-CABG have high-risk cardiovascular disease and require accurate perioperative neurological and hemodynamic evaluation that can be safely provided with local anesthesia. In this retrospective single-center study, 14 patients were systematically identified to have undergone staged TCAR prior to CABG surgery from December 2018 to October 2021. All patients underwent TCAR with local anesthesia and minimal sedation. Relevant patient demographics, medical and surgical history, preoperative covariates, and type of anesthesia administered were obtained from patients' charts. Carotid artery disease was confirmed by either carotid duplex imaging or computed tomography angiography (CTA) of the head/neck. Staged TCAR-CABG interventions were performed on 14 patients (64% male; mean age 65.0 years). No major adverse cardiac events were reported including transient ischemic attack (TIA), stroke, myocardial infarction, or TCAR-related death in the interval between their TCAR and CABG as well as in a 12-month follow-up period. One patient required to return to the operating room (OR) for evacuation of a neck hematoma. This study demonstrated high success rate of TCAR under local anesthesia prior to CABG (100%) with no incidence of perioperative stroke, myocardial infarction (MI), or death at 1-month, 6-month, and 12-month follow-up intervals. The authors support the use of staged TCAR-CABG with local anesthesia as a safe and promising treatment option for patients with high-grade cardiac disease, high risk of stroke, or multiple comorbidities that preclude a CEA.

The surgical anatomy of a (robot-assisted) minimally invasive transcervical esophagectomy.

Transcervical esophagectomy allows for esophagectomy through transcervical access and bypasses the thoracic cavity, thereby eliminating single lung ventilation. A challenging surgical approach demands thorough understanding of the encountered anatomy. This study aims to provide a comprehensive overview of surgical anatomy encountered during the (robot-assisted) minimally invasive transcervical esophagectomy (RACE and MICE). To assess the surgical anatomy of the lower neck and mediastinum, MR images were made of a body donor after, which it was sliced at 24-μm intervals with a cryomacrotome. Images were made every 3 slices resulting in 3.200 images of which a digital 3D multiplanar reconstruction was made. For macroscopic verification, microscopic slices were made and stained every 5 mm (Mallory-Cason). Schematic drawings were made of the 3D reconstruction to demonstrate the course of essential anatomical structures in the operation field and identify anatomical landmarks. Surgical anatomy 'boxes' of three levels (superior thoracic aperture, upper mediastinum, subcarinal) were created. Four landmarks were identified: (i) the course of the thoracic duct in the mediastinum; (ii) the course of the left recurrent laryngeal nerve; (iii) the crossing of the azygos vein right and dorsal of the esophagus; and (iv) the position of the aortic arch, the pulmonary arteries, and veins. The presented 3D reconstruction of unmanipulated human anatomy and schematic 3D 'boxes' provide a comprehensive overview of the surgical anatomy during the RACE or MICE. Our findings provide a useful tool to aid surgeons in learning the complex anatomy of the mediastinum and the exploration of new surgical approaches such as the RACE or MICE.

Thoracic Duct Embolization Using Transabdominal Antegrade and Transcervical Retrograde Accesses

PurposeTo evaluate the technical success and clinical outcomes of thoracic duct embolization (TDE) using transabdominal antegrade and transcervical retrograde accesses to treat patients with chyle leak. Materials and MethodsThis study was a retrospective, nonblinded, single-institution chart review of all patients aged 18 years or older over a 6-year time frame who underwent lymphangiography with attempted TDE for iatrogenic or spontaneous chyle leaks using transabdominal antegrade and/or transcervical retrograde accesses. ResultsNinety-nine patients underwent 113 procedures. Eighty-five patients underwent 1 procedure, and 14 patients required 2 procedures. The technical success rate of TDE was 68% (72/106) with transabdominal antegrade access and 44% (15/34) with transcervical retrograde access. The overall technical success rate of TDE, including both the access methods, was 77% (87/113). The most common reasons for transabdominal access failure were small caliber of the cisterna chyli and thoracic duct (TD) occlusion. Five patients were lost to follow-up. Overall clinical success, defined as resolution of the chyle leak, was achieved in 83% (78/94) of the patients. There were 6 Society of Interventional Radiology (SIR) level 1 adverse events (AEs), 5 SIR level 2 AEs, and 2 SIR level 3 AEs. Nontarget embolization occurred in 2 patients. ConclusionsAlthough transcervical retrograde TDE is a challenging procedure, with a lower technical success rate than transabdominal antegrade access, retrograde access improved the technical and clinical success rates of the treatment of chyle leaks in cases of thoracic duct occlusion, small cisterna chyli, and leaks located in the abdomen.

Transcervical Access for Ultrasound-Guided Biopsy—A Safe Technique to Sample Apical Lung Lesions

AbstractEight patients with apical lobe lung lesions referred for image-guided biopsy where the lesion was abutting the mediastinal or apical pleura, and was visible in ultrasound using a suprasternal–supraclavicular route were consented and subjected to successful ultrasound-guided transcervical biopsy using different routes based on lesion characteristics and location of vital vascular structures—either through the thyroid gland, by the side of the gland lateral to the common carotid artery, or between the thyroid gland and common carotid artery after hydrodissection. Transthyroid access was used in 50% of cases. There were no immediate or long-term complications in any patient over a mean follow-up period of 28.5 months. Sample adequacy was 100%.

Minimal transcervical access single-port endoscopy-assisted thyroidectomy: a retrospective comparative study.

Conventional open thyroidectomy (COT) has been the most common approach for thyroidectomy, with a long incision in the neck, a portion of the body prominently exposed. As the morbidity of thyroid surgery has decreased to become minimal, cosmetic outcomes have emerged as increasingly important, motivating surgeons to develop alternative approaches. To describe our technique of minimal transcervical access single-port endoscopy-assisted thyroidectomy (Huang's procedure - HP) and to compare the results with those of COT. A retrospective comparative study from a prospectively maintained database was performed. Thirty patients who underwent HP (HP group) and 18 patients who underwent COT (COT group) between February 2021 and February 2022 were included. All of the patients were pathologically confirmed to have benign thyroid nodules in one lobe and underwent lobectomy. The incision length of the HP group was obviously shorter than that of the COT group. The patients who underwent HP experienced significantly less postoperative pain and better cosmetic satisfaction. In operative time, intraoperative blood loss, postoperative drainage, postoperative hospital stay, and the incidence of complications, there was no significant difference between the two groups. Minimal transcervical access single-port endoscopy-assisted thyroidectomy (Huang's procedure), in selected patients, is a feasible and safe alternative to COT, and is superior to COT in terms of incision length, postoperative pain and cosmetic satisfaction.

Transcervical Versus Transfemoral Approach in Carotid Stenting Real World Experience in a Community Hospital

Peri-procedural embolic events are the Achilles' heel of carotid stenting. To overcome this complication, transcervical access to the carotid artery was introduced. In this study we describe our "our life" experience with the transcervical approach in a community hospital. All carotid stent procedures between January 2010 and December 2020 were included in this retrospective analysis. The transcervical approach was compared to the transfemoral approach. In both procedures open-cell, closed-cell design and hybrid stents were used. In-hospital stroke was the primary outcome measure. A total of 340 procedures were performed, in 184 patients the transfemoral approach was used and in 156 patients the transcervical approach was used. In 12 patients (3.5%) an in-hospital stroke was diagnosed, 4 in the transfemoral group (2.2%) and 8 in the transcervical group (5.1%) (P=0.14). In the multivariate analyses a symptomatic lesion was associated with in-hospital stroke. Neither type of access nor cell design was associated with increased risk of in-hospital stroke. In contrast to previous studies, we could not confirm the advantages of the transcervical approach. However, conclusions should be carefully drawn, since this study is retrospective and was performed with multiple surgeon and different kind of stents.

Transcervical approach for carotid artery stenting with transitory reversal flow: Case report.

IntroductionCarotid artery stenting (CAS) has been indicated as an alternative to carotid endarterectomy in high risk patients. Sometimes, an aortic arch can be anatomically unfavourable for CAS. Herein we report our experience in a case of CAS with transcervical approach.Presentation of caseA 77-year-old male was referred to our hospital for severe subtotal occlusion of the left internal carotid artery. He had a past medical history of radiation to the head and neck for laryngeal cancer. Previous CT-angiography had shown a type III aortic with bovine arch. CAS via transcervical approach was performed with transitory reversal flow during the placement of RX Spider Filter 6 Fr (Medtronic, Minneapolis, MN). After release of 7 × 30 mm RX Xact carotid stent (Abbott Vascular, Chicago, IL) and ballooning with a 5.5 × 30 mm Rx Submarine balloon catheter (Medtronic Minneapolis, MN), angiography check showed a good result.DiscussionThe transcervical approach is an innovative technique where usually a shunt is created, either between the common carotid artery and the internal jugular vein or between the common carotid artery and the common femoral vein. This flow reversal reduces the risk of periprocedural embolic events. In our experience a short proximal clamping with transitory reversal flow, reduces the invasiveness of procedure with good outcomes.ConclusionTranscervical carotid access with transitory reversal flow is a valid alternative in complicated patient with anatomy unfit for CAS.

The value of thymectomy in the treatment of non-thymomatous myasthenia gravis

Der Stellenwert der Thymektomie in der Therapie der thymomfreien Myasthenia gravis blieb bis vor einiger Zeit umstritten. Die relativ geringe Inzidenz und Prävalenz der Erkrankung, die uneinheitliche Dokumentation in den verschiedenen Studien sowie die notwendige Langzeitbeobachtung zur Erfassung therapeutischer Effekte erschwerten das Generieren valider Daten. Die Veröffentlichung des MGTX-Trials 2016 im New England Journal of Medicine lieferte die ersten randomisiert-kontrollierten Daten, nach denen Patienten mit Acetylcholin-Rezeptor-Antikörper-positiver generalisierter Myasthenia gravis im Alter von 18 bis 65 Jahren von der chirurgischen Resektion des Thymus über eine mediane Sternotomie profitieren. Trotz fehlender Validierung des Vorteils der Thymektomie über minimal-invasive Techniken durch randomisiert-kontrollierte Studien scheinen diese das Outcome bestimmter Patientengruppen in ähnlicher Form positiv zu beeinflussen. So haben videoassistiert-thorakoskopische, roboterassistierte, subxiphoidale und transzervikale Zugangswege nicht nur ästhetische Vorteile, sondern zeigen in der Beeinflussung des Krankheitsverlaufs der Myasthenia gravis keine relevante Unterlegenheit gegenüber der medianen Sternotomie. Doch nicht nur der Nutzen und das ästhetische Ergebnis differieren, sondern auch die Erfolgsaussichten im Hinblick auf die Remission sind bei den Unterformen der Myasthenia gravis unterschiedlich. Die heterogene Gruppe der Myasthenien unterscheidet sich bezüglich des Auftretens von Autoantikörpern, der betroffenen Körperregionen und des Alters der Patienten bei Erstdiagnose. Schließlich ist die Thymektomie eine wirksame kausale Therapie der Myasthenia gravis.

The transcervical access for transcatheter aortic valve replacement.

Alternative accesses for transcatheter aortic valve replacement (TAVR) are needed in a certain number of patients, who present contraindications to the standard transfemoral access. We present the transcervical approach, which allows to access the aortic valve via supra-aortic vessels, namely, the brachiocephalic trunk, carotid artery, or subclavian artery. This approach is interesting because it avoids thoracotomy, which is necessary with some other alternative approaches for TAVR, such as the transaortic or transapical ones. Although some points still need clarification, such as the best anesthesia modality (general or local) or the optimal side for vessel access, data suggest the transcervical access might yield similar periprocedural and 30-day outcomes compared with the transfemoral access. Herein, we describe the surgical technique that was developed in our institution for transcervical access.

Pull-Through Buddy Wire Technique for Endovascular Thrombectomy in Patients with Acute Ischemic Stroke: Technical Note.

Excessive tortuosity is a notable cause of failed endovascular thrombectomy for acute large-vessel occlusion stroke. Transcervical access (TCA) is a commonly proposed solution for overcoming this difficulty. However, the large-bore catheter usually used in TCA increases the risk of serious local complications. This paper presents a modified technique for TCA that uses a pull-through buddy wire (PTBW) to track a large-bore femoral guiding sheath (GS) into the carotid artery via a small carotid puncture site. The carotid puncture site can be easily managed through gentle manual compression. Two illustrative cases using this technique to deal with a large aortic arch and tortuous left common carotid artery are reported. In both cases, recanalization was achieved after successful GS placement. Using a PTBW is feasible in TCA.

Direct Carotid Puncture for Emergent Thrombectomy: 2-Dimensional Operative Video.

Emergent thrombectomy for large vessel occlusion is now a standard procedure within neurosurgery. In general, thrombectomy is attempted via a femoral artery puncture. However, due to anatomic variability and arterial tortuosity, target vessels cannot be catheterized in roughly 5% of patients.1 Radial artery access is an alternative to femoral artery access; however, target arteries for thrombectomy cannot be catheterized via the femoral or radial arteries in a small subset of patients. Direct carotid puncture is an alternative route of access for emergent thrombectomy in acute stroke.2,3 In this video, we present a patient with an acute right middle cerebral artery occlusion who was taken for emergent thrombectomy after consenting for the procedure. Because of unfavorable arterial anatomy, the right internal carotid artery could not be successfully catheterized via femoral or radial arterial punctures. We ultimately catheterized the right internal carotid artery and middle cerebral artery via a direct carotid puncture. We review the technique for direct carotid puncture, and discuss the outcomes associated with this method of access in the setting of acute large vessel occlusion. We also discuss complications associated with direct carotid puncture. Direct carotid puncture is an acceptable bail-out technique in the setting of emergent thrombectomy when femoral and/or radial access is not possible. Figure at 2:18 republished from Sekhar LN, Iwai Y, Wright DC, Bloom M. Vein graft replacement of the middle cerebral artery after unsuccessful embolectomy: case report. Neurosurgery. 1993;33(4):723-727, by permission of the Congress of Neurological Surgeons. Table at 6:05 modified from Roche A, Griffin E, Looby S, et al. Direct carotid puncture for endovascular thrombectomy in acute ischemic stroke. J NeuroIntervent Surg. 2019;11(7):647-652, ©The Authors, 2019, with permission from Dr Sarah Power. Table at 6:22 reproduced from Jadkhav AP, Ribo M, Grandhi R, et al. Transcervical access in acute ischemic stroke. J NeuroIntervent Surg. 2014:6(9):652-657, ©2013, with permission from the BMJ Publishing Group Ltd.

Outcomes of Transcarotid Artery Revascularization and Carotid Endarterectomy at a Single Institution

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are accepted revascularization modalities to treat carotid artery stenosis. Higher incidences of perioperative adverse neurological events and death have been reported in patients with transfemoral CAS. Transcarotid artery revascularization (TCAR) is a newer operative technique that involves direct transcervical carotid access, mitigating aortic arch manipulation and minimizing the risk of embolic stroke via cerebral blood flow reversal. Perioperative stroke, myocardial infarction (MI), and death rates have been shown to be similar between TCAR and CEA, with TCAR having fewer complications. The objective of this study was to ascertain the safety and viability of TCAR by evaluating perioperative outcomes. We hypothesized that patients undergoing TCAR and CEA have equivalent outcomes. We performed a single-institution retrospective review of a prospectively maintained Vascular Quality Initiative database on patients who underwent TCAR or CEA between 2012 and 2019. A total of 66 TCAR cases from February 2018 to December 2019 and 501 CEA cases from January 2012 to December 2019 were reviewed. Preoperative, intraoperative, and postoperative characteristics as well as perioperative outcomes were captured for the statistical analyses. From 2012 to 2019, 567 patients underwent TCAR or CEA. Patients who underwent TCAR were found to have higher rates of comorbidities compared with CEA. There were no procedure-related strokes in patients who underwent TCAR. There was no statistically significant difference between TCAR and CEA procedure-related strokes (0% vs. 1.0%, P=0.42). There were 5 CEA procedure-related strokes because of technical problems resulting in thrombosis of the target vessels. Three patients who underwent CEA had strokes unrelated to the operations. Overall, there were no perioperative deaths, MI, cranial nerve injury (CNI), or hematoma in patients who underwent TCAR. There were no complications of surgical site infection, pseudoaneurysm, or arteriovenous fistula among patients who underwent TCAR or CEA. This single-center retrospective analysis of TCAR and CEA for the treatment of carotid artery disease suggests TCAR can result in equivalent perioperative procedure-related stroke as CEA as well as equivalent incidence of perioperative complications including MI, CNI, hematoma, and death in selected patients or patients with proper anatomy. TCAR may be considered a safe, feasible carotid revascularization option for carotid artery stenosis.

SEGMENTAL RESECTION OF THE MANDIBLE FOR THE TREATMENT OF DESMOPLASTIC AMELOBLASTOMA: A CASE STUDY

The patient was referred to the buccomaxillofacial surgery and trauma unit, with a diagnosis of desmoplastic ameloblastoma after incisional biopsy, which was carried out in another department. An increase of the volume in the anterior region of the mandible, which was painless to the touch, was observed at the extra-oral physical examination. The intra-oral examination showed incisor crowding. During the tomographic exam, a multilocular radiolucent lesion, with irregular limits and root resorptions, was also observed. The segmental resection was carried out under general anesthesia with safety margin of 2 centimeters, through transcervical access. Two reconstructive plates were fixed to preserve the bed, as well as to strengthen the bone structure. Currently, after 2 postoperative years, the patient is undergoing outpatient follow-up, because the event of recurrence has been observed even after many years of the initial treatment and in mandibular reconstructive plans.

Completion thyroidectomy: is timing important for transcervical and remote access approaches?

Completion thyroidectomy (CT) is employed after lobectomy when histopathological results mandates total removal of the gland as in case of well differentiated thyroid carcinoma (DTC). It is also employed as a second stage thyroid surgery when unfavorable events occur as in recurrent laryngeal nerve injury or when the surgeon finds out the case is beyond his/her expertise in an attempt to protect the contralateral side and allowing time for recovery or for an expert surgeon to help.

Atrophic jaw fracture and predictability in oral rehabilitation: case report

Introduction: The treatment of atrophic jaw fractures requires extensive knowledge by the maxillofacial surgeon. The correct diagnosis and planning optimize the possibility of oral rehabilitation towards many possible alternatives. The difficulty in repairing these fractures makes the treatment complex, in which normally invasive techniques are used. However; which give us satisfactory and predictable aesthetic-functional results. Objective: The objective of this work is to report an atrophic jaw fracture and posterior dental implants rehabilitation. Case report: A 53 years old female patient, victim of in face aggression referred to the emergency care. At the clinical examination, the patient had laceration in the upper lip region and the left side of the mandibular area, with bilateral mobility and paresis. In the oral examination, total lower and partial upper edentulism. After tomographic evaluation, a bilateral fracture of the mandibular body was confirmed, with significant bone fragments uneven. Surgery was performed with total transcervical access and use of reconstruction plate. After 90 days of follow-up, the oral rehabilitation with osseointegrated implants was performed. Conclusion: Complex atrophic mandible fractures in total edentulous patients can be treated with open reduction and stable fixation, allowing a faster return to normal function, improve of quality of life and assists in increasing safety for implant installation.KeywordsEdentulous jaw; Jaw fixation techniques; Dental implants.