Transcervical Approach Research Articles

Transcervical videomediastino-thoracoscopy.

Although technical advances in non-invasive and minimally invasive approaches to lung and pleural cancer diagnosis and staging have become more widely available and accurate, surgical techniques remain the gold standard in assessing the extent of loco-regional involvement. Precise surgical staging of lung or pleural tumours is pivotal in the selection of surgical candidates and for predicting survival. In some patients, both mediastinal and pleural exploration may be needed for many different reasons. Transcervical videomediastino-thoracoscopy (VMT) combines simultaneously the exploration of both the mediastinum and the pleural cavities through a single cervical incision, allowing for biopsies or sampling of the mediastinal lymph nodes, lymphadenectomy and pleuropulmonary assessment (mainly pleural effusions, tumour involvement of the visceral and parietal pleura and pulmonary nodules). Thoracic surgeons should be aware of this combined surgical approach and completely familiar with classical indications and technical details of the transcervical approach to the mediastinum and thoracoscopic exploration of the pleural cavities.

Complications in modern hysteroscopic myomectomy.

Uterine fibroids (UFs) are common benign tumors of the female genital tract, diagnosed in almost one-quarter of women of reproductive age. UFs may cause numerous clinical symptoms, including prolonged or heavy menstrual bleeding, pelvic pressure symptoms, pain, infertility and others. Submucous fibroids arise from the muscular part of the uterus and pen-etrate into the uterine cavity. They are mostly managed with the use of hysteroscopic myomectomy (HM), which provides direct visualization from the transcervical approach. The sheer number of HM standards and techniques is reason enough to review the available literature about HM-related complications. HM is a safe and effective treatment in patients with the normal size of the uterus and with no more than a few UFs. The procedure should not be initiated without adequate preparation and diagnosis, using the best methods available.

Transoral endoscopic radical resection for a recurrent pyriform sinus fistula

Abstract In revision surgery for a recurrent pyriform sinus fistula (PSF), complete resection of the fistula via a transcervical approach is difficult because of the surrounding scar tissue that results from previous surgery and infections. We successfully performed transoral endoscopic radical resection of the fistula for a recurrent PSF in two patients. Approaching the fistula from the orifice is reasonable and radical resection of the fistula is a reliable procedure in revision surgery. Transoral endoscopic resection is a feasible surgical option for a recurrent PSF.

Transoral videoendoscopic resection of head-and-neck Tumors in 4-hand technique

Videoendoscopic surgery in 4-hand technique is a standard procedure in laparoscopic and also in transsphenoidal pituitary operations. In recent years transoral videoendoscopic resection of head and neck tumours in 4-hand technique (TOVR) gained more and more importance. From March 2013 28 transoral videoendoscopic resections of oropharyngeal (n = 5)-, hypopharyngeal (n = 12) and laryngeal (n = 11) carcinomas in 4-hand technique werde successfully performed. In all 28 cases a R0-resection without extension to a transcervical surgical approach was achieved transorally. Even in patients with minor mobility of the cervical vertebral column (n = 9) and reduced adjustment facilities of the Kleinsasser laryngoscope or Weerda distending laryngoscope transoral tumor resection could be successfully performed with the use of rigid angular optics. TOVR is an effective, cheap and minimally invasive surgical procedure featuring numerous advantages compared to CO2 laser resection and can be considered as real alternative for traditional resection methods of head and neck tumours.

Surgical Management of Parapharyngeal Space Tumours in a Single Tertiary Care Center.

Because of the inaccessibility and overcrowding of the vital neurovascular structures, management of the parapharyngeal space (PPS) tumouris always a challenge to the surgeons. Here we have discussed the clinical findings and management of the PPS tumours with special concern to the surgical approaches. It is a retrospective study containing 14 patients of PPS tumour from June 2015 to January 2018 in the department of Otorhinolaryngology and Head Neck Surgery in a tertiary care referral hospital. 14 consecutive patients with PPS tumours were included in the study. The retrospective clinical data, diagnostic procedures, surgical approaches and the complications were analyzed after 12 months of surgery. Of 14 patients included in the study, 10 patients were males and 4 were females. Prestyloid and poststyloid spaces were involved in 28.57% and 71.42% cases respectively. Transcervical excision of the tumours were performed in 10 patients, 2 patients had undergone transcervical-transoral approach. Transcervical transmandibular and transcervical transparotid excision of tumours were performed in one patient each. Facial nerve injury was detected in 3(21.42%) patients. Injury to the internal carotid artery and wound infection were detected in one patient each. Radiological imaging, especially the MRI helps by narrowing the spectrum of the differential diagnosis distinguishing the benign from malignant lesions, especially in cases where FNAC is contraindicated. Although the transcervical approach is commonly practiced, the combined surgical approach can be effectively applied specially for extensive PPS tumours associatedwith satisfactory clinical outcomes.

Transcervical approach for oropharyngeal cancer

Introduction . With the advance of new technology like endoscopic laser and robotic surgery the interest in surgical treatment of the oropharyngeal cancer has been icreasing. However, the possibilities of the traditional techniques are not fully understood. The study objective is to analyze functional and oncologic results of transcervical approach in surgical treatment of oropharyngeal cancer. Materials and methods . Since April, 2009 through August, 2016 47 patients with oropharyngeal cancer (34 male and 13 female, aged between 44 and 69 years, mean – 57.6) were operated on through the transcervical approach. All but 2 patients with adenoid cystic (1) and acinic cell (1) had squamous cell carcinoma; 27 tumors originated from the tonsil, 13 – from the base of the tongue, 7 – from the soft palate; 42 (89.4 %) patients had stage III–IV disease. Among them 28 (60 %) were diagnosed with T3–T4 primary tumors; 37 (79 %) patients hadmetastases in lymph nodes. Perioperative tracheostomy was performed in all cases. All patients underwent neck dissection that was bilateral in 3 cases. Modified radical was the most frequent type of neck dissection. The operative approach was enhanced by lip-splitting in 12 patients who had marginal mandibulectomy. Local tissues were used for the reconstruction of the pharyngeal defect in 22 patients. In 25 cases flaps were used: free flaps – in 15, regional flaps with axial blood supply – in 10; thereafter 28 patients received adjuvant radiation with or without chemotherapy. Survival was calculated according to Kaplan–Mayer method. Results . There was 1 death in early postoperative period with the death rate of 2.1 %. Complications were registered in 13 patients (28 %), 4 of them had multiple complications: total or partial flap necrosis – 6, wound infection – 4, postoperative bleeding – 2, perforative duodenal ulcer – 1, gastric bleeding – 1, neck wound breakdown – 1, pharyngeal wound breakdown – 1. Salivary fistula developed in 3 patients (6.5 %). Tracheostomy tube was removed on postoperative day 6.4 on average. In 43 (91.5 %) cases patients were able to resume oral diet 14 days after the operation on average. The mean follow up was 31.1 (3–101) months. Overall 3-year survival was 54.7 % with 63 % locoregional control. Locoregional failure was the most common cause of death – in 13 patients. Among 26 long-term survivors 25 are able to take food orally, 1 (3.8 %) patient remains to be gastrostomy tube dependent. Conclusion . Transcervical approach for oropharyngeal cancer is a valuable alternative to mandibulotomy because it characterized by acceptable functional results.

Intraoperative Ultrasound-Guided Retrieval of an Extraluminal Pharyngoesophageal Foreign Body

Pharyngoesophageal foreign bodies (FBs) are common otolaryngologic problems, but challenging cases cause significant patient and surgeon frustration. Extraluminal migration of an FB from the pharynx or esophagus is rare and usually necessitates external neck exploration. Approaching these complicated FBs endoscopically may avoid undue surgical morbidity. We present a case using real-time, intraoperative ultrasound (US) guidance for safe retrieval of a migrated submucosal FB. Intraoperative US is a widely available, powerful technology that can aid in the retrieval of difficult pharyngoesophageal FBs. In appropriate cases, this strategy may circumvent transcervical approaches and their associated risks.

Parapharyngeal Space Tumor: Submandibular Approach Without Mandibulotomy.

Among all head and neck tumors, only 0.5% occur in the parapharyngeal space and 80% are benign tumors. Surgery is the cornerstone of treatment. The deep location of this space and surrounding structures has given rise to a large number of surgical approaches for resection of parapharyngeal neoplasms. Our experience using the submandibular transcervical approach on 14 patients who had surgery upfront for treatment of these lesions is described. This is a retrospective, descriptive case-series analysis of patients with parapharyngeal space tumors treated from January 2009 to July 2016, in whom carotid body tumors were excluded. Fourteen patients were included, 11 females (76.9%) and 3 males (23.1%), with a mean age of 46.9years (SD 14.85). The most common symptom reported at patient's presentation to our clinic was a foreign body sensation in the oropharynx and pain. Navigation-guided surgery was used in two cases. Mean tumor size was 4.7cm (SD 1.785). Complete resection of lesions was performed in all cases, and the major complication was massive bleeding in one case (7.1%). According to the present analysis, the submandibular transcervical approach is an effective and safe technique that allows resection of large parapharyngeal tumors, even those close to the skull base. It has minimal complication rate, prevents morbidity associated mandibulotomy and allows extension to a transparotid, transmandibular and even to an infratemporal fossa approach. Navigation is indicated in tumors < 2cm. The submandibular transcervical approach should be considered upfront for neoplasms ≤ 7cm, preferentially ≥ 0.5cm distant from skull base.

Surgical treatment results of parapharyngeal space tumors: a report of 22 cases.

Parapharyngeal space (PPS) is the anatomical area lateral to the upper pharynx and clinically important due to PPS tumors. They account for less than 1% of head and neck neoplasms. Both benign and malignant neoplasms may arise there and typical for this localization is diversity of histological origin. Complete surgical excision is still the basis of treatment. Evaluation of the results of surgical treatment of PPS tumors in the Department of Otolaryngology at the Medical University over the period 2015-2017. A retrospective analysis of medical records including complaints, physical examination, results of imaging studies, surgical approach, postoperative complication and histopathological results in 22 patients with a diagnosis of a PPS tumors. The most frequent complaints reported by the patients were: discomfort in the throat, dysphagia, hearing disorders and a palpable tumor on the neck. Asymptomatic course of the disease was demonstrated in 4 cases. All patients were treated surgically: 2 with transoral approach, 9 with transparotid-transcervical approach, 11 with transcervical approach. In most cases the tumor was removed radically. In 2 patients intracapsular tumor resection was performed. Based on histopathological examination the benign lesions dominated (18/22). In 4 cases malignant neoplasms were diagnosed: carcinoma ex pleomorphic adenoma, adenoid cystic carcinoma and two cases of squamous cell carcinoma. The most common origin of PPS tumors was deep lobe of parotid gland and for this group 11 patients had diagnosis of pleomorphic adenoma. Other diagnosis included: paraganglioma, neurofibroma, hemangioma, lymphangioma and rhabdomyoma. Postoperative complications occurred in 9 patients and presented as hoarseness and dysphagia due to paresis of the lower group of cranial nerves (IX, X, XII). Significant intraoperative bleeding during surgery occurred in 2 cases and ligation of the external carotid artery was necessary. Due to the anatomical topography of PPS and its content with the essential vessels and the lower group of cranial nerves, the surgical treatment of pathology of this area is still a challenge for head and neck surgeons. The decrease of voice quality and impaired speech and swallowing should always be considered as complications post the surgical resection in PPS.

Surgical management of patients with Eagle syndrome

ObjectiveEagle syndrome, a spectrum of disease resulting from an elongated styloid process and/or calcified stylohyoid ligament, lacks standardized recommendations regarding indications for surgical intervention and approach. Study designRetrospective cohort study. SettingSingle tertiary care institution. SubjectsPatients treated surgically for Eagle syndrome between January 2011 and June 2017. MethodsPatients were diagnosed with Eagle syndrome based on thorough clinical workup and assessment. The primary outcome was improvement in pain severity following surgery, with complete resolution of pain being considered clinically meaningful. Wilcoxon rank-sum tests and Fisher's exact were used to compare numerical and categorical variables, respectively. ResultsTwenty-one patients were diagnosed with Eagle syndrome and underwent surgical resection of the styloid process. Patients most often complained of neck pain (81%), throat pain (62%), and ear pain (48%). Among these patients, 57% of procedures featured a transcervical approach, while the remaining 43% were transoral. The vast majority (90%) of patients experienced improvement in pain severity from a median of 6.0 before surgery to 0.0 afterwards (p < 0.01) as 62% experienced complete resolution. Using multivariable linear regression to model changes in pain severity, neck pain (β = −1.69, p < 0.01) and jaw pain (β = −0.93, p = 0.03) predicted greater relief, while headache (β = 0.82, p = 0.04) predicted an inferior response. Adverse events were uncommon and typically resolved within three months, with 24% experiencing first bite syndrome and 19% reporting numbness. ConclusionsTranscervical and transoral styloidectomy are effective treatments for Eagle syndrome with minimal adverse effects. Patients with classic symptoms of neck or jaw pain benefit most from surgery.

Aberrant Thyroid in the Parapharyngeal Space

Introduction&#x0D; Aberrant thyroid is a mass of tissue having the structure of a normal or pathological thyroid gland and situated at some definite distance from normal thyroid, with which it has no connection. The prevalance of ectopic thyroid is 1 case per 100,000- 300,000 persons1 and the incidence of aberrant thyroid in parapharyngeal space is even rarer.&#x0D; Materials and Methods&#x0D; A rare case of aberrant thyroid in parapharyngeal space is reported, which presented as oropharyngeal mass and dysphagia. She also had thyroid gland in the usual position.&#x0D; Result&#x0D; She was managed surgically with transcervical approach and was euthyroid postoperatively.&#x0D; Conclusion&#x0D; Aberrant thyroid should be one of the differential diagnoses for parapharyngeal space masses.

Transcervical thymectomy

Background: The aim of this article is to describe the technique of minimally invasive extended thymectomy performed through the transcervical video-thoracoscopic (VATS) approach with elevation of the sternum for the thymic tumors with/without myasthenia gravis (MG). Methods: The operation is done through the collar incision in the neck of a length of 4–8 cm. To facilitate an access to the mediastinum a one-tooth hook connected to the Zakopane bar (Aesculap-Chifa, Nowy Tomysl, Poland) is inserted under the sternal notch for elevation of the sternum. Careful anatomical dissection of the structures of the lower neck region is done with preservation from injury of the thyroid gland, the parathyroid glands and both laryngeal recurrent nerves. The thymus gland is resected en-bloc with the surrounding fatty tissue of the lower neck and the anterior superior mediastinum. The blood vessels supplying the thymus are secured and divided—these are inferior thyroid veins and the thymic veins. For better control, a video-thoracoscope (VATS) is inserted to the mediastinum through the cervical incision. The lowers poles of the thymus are separated from the pericardium and the specimen is removed. Usually, the right lower pole is dissected first and the left lower pole is managed during further dissection of the aortopulmonary window is a difficult, but very important part of transcervical thymectomy. Results: There were 18 patients (2 for MG with associated thymic tumors and 16 for the tumors/cysts of the anterior mediastinum without MG) in the period 1/1/2009 to 31/12/2017. The morbidity was 5.6%, with no mortality. The mean time of the procedure was 105.4 min (45–150 min). Conclusions: The transcervical approach combined with VATS and lifting of the sternum facilitates thymectomy in case of small thymic tumors with/without MG. This technique is more difficult and less extensive that subxiphoid thymectomy.

Infrahyoid involvement may be a high-risk factor in the management of non-odontogenic deep neck infection: Retrospective study

ObjectivesThis study sought to investigate the impact of involvement of the infrahyoid neck space on the management of non-odontogenic DNI. MethodEighty-one patients treated for non-odontogenic DNI over 5 years were retrospectively recruited into this study. Demographics, etiology, radiology results, treatments, duration/cost of hospital stay, and complications were recorded. Differences between DNIs with and without infrahyoid involvement, as defined based on an anatomical chart, were analyzed. ResultsSixty-two male and 19 female patients with a median age of 46.22 years were included. Fifteen patients had cellulitis, and 66 patients had abscesses. Streptococcus was the most commonly observed bacterium. Compared with DNIs only in suprahyoid spaces (n = 60, 74.07%), DNIs with infrahyoid space involvement (n = 21, 25.93%) were associated with higher incidences of the involvement of ≥3 spaces (85.71%, P = 0.000), mediastinitis (38.10%, P = 0.000), tracheostomy (28.57%, P = 0.008), surgery using a transcervical approach (66.67%, P = 0.000), and intensive care unit therapy (19.05%, P = 0.004), as well as longer hospital stays (16 days, P = 0.000) and higher costs ($2872, P = 0.000). ConclusionInfrahyoid involvement should be regarded as a high-risk factor in the management of deep neck infection (DNI). A relatively aggressive plan that includes transcervical surgery and tracheostomy should be considered at earlier stages for DNI with infrahyoid involvement.

Transcervical uniportal pulmonary lobectomy

The aim of the study is a description of surgical technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) for pulmonary lobectomy. We used a collar neck incision (transcervical) of an average length 5-8 centimeters. The manubrium of the sternum is elevated with a hook connected to the Zakopane II frame (Aesculap-Chifa, B. Braun, Nowy Tomyśl, Poland). The first step is a transcervical extended mediastinal lymphadenectomy (TEMLA), for improved staging and possible improved survival. The nodes removed during TEMLA undergo intraoperative imprint cytology examination. In case of no metastasis a uniportal VATS lobectomy through the neck follows. Ventilation of the operated lung is disconnected and the pleural cavity is entered by opening of the mediastinal pleura. Pleural adhesions, if present are managed with electrocautery. The branches of the pulmonary artery and vein are sequentially dissected and managed with endostaplers or vascular clips. The lobar bronchus and the fissures are divided with endostaplers and the resected lobe is removed in an endobag. There were 16 patients operated on in the period 1.2.2016-30.7.2016. There were two conversions-in one patient with left lower lobe tumor we had to convert to uniportal VATS left lower lobectomy due to extensive adhesions. In the other patient undergoing right lower lobectomy there was a conversion to right thoracotomy because of the bleeding from the pulmonary artery. There was no mortality and complications occurred in three patients. The mean operative time was 245.6 min (range, 145-385 min) for the whole TEMLA procedure with imprint cytology and lobectomy and 175.6 min (range, 75-295 min) for a lobectomy solely. A uniportal transcervical VATS approach for pulmonary lobectomy combined with transcervical extended mediastinal lobectomy (TEMLA) provides an opportunity for radical pulmonary resection and superradical extensive mediastinal lymphadenectomy.

Walk the Line. The Surgical Highways to the Craniovertebral Junction in Endoscopic Approaches: A Historical Perspective.

We compiled a comprehensive literature review on the anatomic and clinical results of endoscopic approaches to the craniocervical junction (CVJ) to better contribute to identify the best strategy. An updated literature review was performed in the PubMed, OVID, and Google Scholar medical databases, using the terms "Craniovertebral junction," "Transoral approach," "Transnasal approach," "Transcervical approach," "Endoscopic endonasal approach," "Endoscopic transoral approach," "Endoscopic transcervical approach." Clinical series, anatomic studies, and comparative studies were reviewed. Pure endonasal and cervical endoscopic approaches still have some disadvantages, including the learning curve and the deeper surgical field. Endoscopically assisted transoral surgery with 30° endoscopes represents an emerging option to standard microsurgical techniques for transoral approaches to the anterior CVJ. This approach should be considered as complementary rather than an alternative to the traditional microsurgical transoral-transpharyngeal approach. The transoral approach with sparing of the soft palate still remains the gold standard compared with the pure transnasal and transcervical approaches because of the wider working channel provided by theformer technique. The transnasal endoscopic approach alone appears to be superior when the CVJlesion exceeds the upper limit of the inferior third of the clivus.

Retrospective analysis of 188 cases of parapharyngeal space tumors

Objective:To explore the diagnosis,treatment,surgical approach and prognosis of parapharyngeal space tumors.Method:The clinical data of 188 patients with parapharyngeal space tumor who were treated from January 2007 to December 2016 were analyzed retrospectively.All patients underwent imaging examination before operation.Surgical approach was as follows:transcervical approach applied in 159 cases,endoscopic-assisted transnasal approach in 9 cases,transcervical-transmandibular approach in 8 cases,transcervical-transparotid approach in 8 cases,transoral approach in 7 cases,and infratemporal fossa approach in 4 case.Result:Of the 188 cases,the tumor was benign in nature in 168 cases(89%)and malignant in 20 cases(11%).Complications occurred in 28(15%)patients,with the most common symptom being hoarseness.168 cases of benign tumors were followed up for 10 months to 10 years,and 3 cases were lost and 4 cases had recurrence.All cases underwent re-operation.Patients with malignant tumors received combined treatment after surgery,and 3 cases were lost to follow-up,1 case died of recurrence 9 months after surgery,the rest survived.Conclusion:Surgery is the preferred method for treating parapharyngeal space tumors and postoperative recurrence rate is pretty low.Endoscopy provides a new surgical management method,helping to reduce postoperative complications and recurrence rate.

Complications and Reoperations in Mandibular Angle Fractures.

Mandible angle fractures can be repaired in a variety of ways, with no consensus on the outcomes of complications and reoperation rates. To analyze patient, injury, and surgical factors, including approach to the angle and plating technique, associated with postoperative complications, as well as the rate of reoperation with regard to mandible angle fractures. Retrospective cohort study analyzing the surgical outcomes of patients with mandible angle fractures between January 1, 2000, and December 31, 2015, who underwent open reduction and internal fixation. Patients were eligible if they were aged 18 years or older, had 3 or less mandible fractures with 1 involving the mandibular angle, and had adequate follow-up data. Patients with comminuted angle fractures, bilateral angle fractures, and multiple surgical approaches were excluded. A total of 135 patients were included in the study. All procedures were conducted at a single, large academic hospital located in an urban setting. Major complications and reoperation rates. Major complications included in this study were nonunion, malunion, severe malocclusion, severe infection, and exposed hardware. Of 135 patients 113 (83.7%) were men; median age was 29 years (range, 18-82 years). Eighty-seven patients (64.4%) underwent the transcervical approach and 48 patients (35.6%) received the transoral approach. Fifteen (17.2%) patients in the transcervical group and 9 (18.8%) patients in the transoral group experienced major complications (difference, 1%; 95% CI, -8% to 10%). Thirteen (14.9%) patients in the transcervical group and 8 (16.7%) patients in the transoral group underwent reoperations (difference, 2%; 95% CI, -13% to 17%). Active smoking had a significant effect on the rate of major complications (odds ratio, 4.04; 95% CI, 1.07 to 15.34; P = .04). During repair of noncomminuted mandibular angle fractures, both of the commonly used approaches-transcervical and transoral-can be used during treatment with equal rates of complication and risk of reoperation. For a patient undergoing surgery for mandibular angle fracture, smoking status is more likely to predict surgical outcomes rather than how the surgeon chooses to approach and fixate the fracture. 3.

The Transcervical Extended Access, a Feasible Approach for the Surgical Treatment of Benign Tumors of the Posterior Mediastinum?

Transcervical approach for tumors of the posterior mediastinum is traditionally thought not to be indicated. Hereby we report on a case of a patient with a huge neurogenic tumor of the posterior mediastinum which was successfully excised through a transcervical extended approach and, additionally, the variety of surgical approaches used to remove tumors of the posterior mediastinum is discussed. The new refined techniques of transcervical extended mediastinal operations, which are recently gaining popularity among surgeons, allowed for a safe dissection of the tumor, thus patient could benefit from a short painless postoperative course. The authors suggest that surgeons trained in these particular techniques should consider the choice of the transcervical extended access in selected cases of benign tumors of the posterior mediastinum.

One-Year Results of the ROADSTER Multicenter Trial of Transcarotid Stenting With Dynamic Flow Reversal

The aim of this study was to report the 1-year outcomes of the transcarotid artery stenting (TCAR) with cerebral blood flow reversal (ROADSTER) multicenter trial and to evaluate the durability of TCAR. This trial introduced a novel transcarotid neuroprotection system (ENROUTE Transcarotid NPS; Silk Road Medical Inc, Sunnyvale, Calif). Overall 30-day stroke rate was 1.4%, which was the lowest reported in any clinical trial for carotid artery stenting. This study is a prospective, single-arm clinical trial. Enrollment occurred in 14 centers. Primary end points were incidence rates of ipsilateral stroke and death at 1 year after TCAR. Occurrence of stroke was ascertained by an independent clinical event committee. Overall, 219 patients were enrolled (pivotal phase, 141; extended access, 78 patients). Of those, 164 patients were included in the 1-year follow-up (16 had postoperative events, 3 died, 10 declined to participate, and 26 were lost to follow-up). Mean age was 73.9 years (range, 42.1-91.3 years). Patients aged 75 years and older were 43.3% of the cohort; 34.8% of patients were female, 92.7% were white, and 5.5% were African American. Most patients were asymptomatic (79.9%). Patients with anatomic risk factors were distributed as follows: contralateral carotid artery occlusion, 11.0%; tandem stenosis of >70%, 1.8%; high cervical carotid artery stenosis, 25.0%; restenosis after CEA, 25.6%; and bilateral stenosis requiring treatment, 4.3%. Hostile neck was the indication for TCAR in 14.6% of cases. Physiologic high-risk factors including two-vessel coronary artery disease were reported in 14.0% of the participants, and severe left ventricular dysfunction (left ventricular ejection fraction <30%) was reported in three (1.8%) patients. Overall, anatomic and physiologic high-risk factors were reported in 43.3% and 29.9% of patients, respectively. Both subsets of factors were present in 26.8% of the entire cohort. At 1-year follow-up, ipsilateral stroke incidence rate was 0.6%, and overall mortality rate was 3.7%. The 1-year risk of stroke found in this study is the lowest to date to be reported in any Food and Drug Administration-approved carotid stent (Fig). Transcarotid artery revascularization with dynamic flow reversal had previously shown favorable 30-day perioperative outcomes. This excellent performance seems to extend to 1 year after TCAR as illustrated in this analysis. The promising results from the ROADSTER trial might stem from the novel cerebral protection provided through the ENROUTE Transcarotid NPS in comparison to distal protection devices. The transcervical approach circumvents aortic arch manipulation that takes place through the transfemoral approach. TCAR offers a potentially safe alternative option for patients who are deemed to be at high risk for CEA.

Endoscopic Transseptal Approach with Posterior Nasal Spine Removal: A Wide Surgical Corridor to the Craniovertebral Junction and Odontoid: Technical Note and Case Series.

The transnasal approach to lesions involving the craniovertebral junction represents a technical challenge because of limited inferior exposure. The endoscopic transseptal approach (EtsA) with posterior nasal spine (PNS) removal is described. This technique can create a wide exposure of the craniovertebral junction, thereby increasing the caudal exposure. On patients undergoing anterior craniovertebral junction decompression, we calculated the degree of exposure on the sagittal plan through a paraseptal route, an EtsA without and with PNS removal. The horizontal exposure and working area with the latter approach were also evaluated. Five patients underwent the transnasal procedure. The age of patients ranged from 34-71 years. All patients harbored basilar impression. The mean postoperative Nurick grade (1, 8) was improved versus the average preoperative grade (3). The average follow-up duration was 16 months. All patients underwent occipitocervical fixation. The mean vertical distances, from the clinoid recess to the inferior most limit with the paraseptal approach, EtsA without and with PNS removal were 38.52, 44.12, and 51.16 mm, respectively. The difference between our approach and a standard paraseptal route was statistically significant (P= 0.041; P< 0.05). The mean horizontal distances were 31.68 mm (mononostril entry) and 35.37 mm (binostril entry). The mean working area was 1795.53 mm2. Endoscopic endonasal approaches to the craniovertebral junction are increasing, but the downward extension on the anterior cervical spine represents a limit. Therefore, many surgeons prefer transoral or transcervical approaches. The EtsA with PNS removal allows for a more caudal exposure than the standard paraseptal approach, with reduced nasal trauma.