Transcervical Approach Research Articles

Surgical treatment of descending necrotising mediastinitis caused by odontogenic infection: aretrospective analysis of 20 patients.

Analysing the results of patients with odontogenic descending necrotising mediastinitis (DNM) treated predominantly by transcervical approach. Odontogenic DNM is a rare but serious complication of dental disease and dental procedures. Retrospective evaluation of 20 patients who underwent surgery for odontogenic DNM. The mean age was 33.95±12.24 years, and 18 patients (90 %) were men. Type I and diffuse form of DNM were identified in 8 (40 %) and 12 (60 %) patients, respectively. The mean time between the onset of symptoms and surgery was 7.16±4.23 days. The transcervical approach was used in 16 patients, combined cervicotomy and subxiphoid incision in three patients, and cervicotomy and posterolateral thoracotomy was used in one patient. Four patients were reoperated. The mean mediastinal drainage duration and postoperative length of stay (LOS) were 17.05±10.27 days and 20.70±10.87 days, respectively. Fourteen (70 %) patients received mechanical ventilation with a mean duration of 8.86±9.55 days. Comorbidities were present in five (26 %) patients; there were complications in 17 (85 %) patients. In-hospital mortality reached 5 % (1 patient). Thirty-five teeth were extracted. Lower mandibular molars represented 21 (62 %) of extracted teeth. Submandibular and submental spaces were the most affected by the presence of deep neck infection (five and four cases, respectively). This study supports the role of transcervical mediastinal drainage as an alternative approach in the surgical treatment of odontogenic DNM (Tab. 4, Fig. 2, Ref. 30).

Parapharyngeal Schwannoma Mimicking Peritonsillar Abscess in a Young Female: A Rare Case Report

Parapharyngeal Space (PPS) tumours are responsible for 0.5% of head and neck cancers. Presenting features can mimic Peritonsillar Abscess (PTA). A differential diagnosis of PPS tumour should therefore be considered in young, systemically well patients with peritonsillar masses that are refractory to antibiotic therapy. This report focuses on a rare case of parapharyngeal schwannoma in an otherwise fit 29-year-old female, who presented with a three month history of a right sided oropharyngeal swelling and a sensation of ‘something’ in her throat. Blood tests, specifically full blood count and C-Reactive Protein (CRP) were normal and attempts at aspiration under local anaesthetic yielded no pus. As the patient showed no signs of improvement despite Intravenous (i.v.) antibiotics and steroid therapy; further investigations were initiated including Flexible Nasoendoscopy (FNE) and contrast enhanced Magnetic Resonance Imaging (MRI) of the neck. The FNE revealed a right sided parapharyngeal mass which was later confirmed on MRI scanning, measuring 7 cm in craniocaudal dimension arising from the deep lobe of the parotid gland. After a fine needle aspiration yielded inconclusive histological evidence, Multidisciplinary Team (MDT) discussion advised surgical excision. The patient underwent excision of the right parapharyngeal tumour and right partial parotidectomy via a transparotid and transcervical approach utilising a modified blair incision and a facial nerve monitor. Histology confirmed a parapharyngeal schwannoma. Postoperative outcomes have been reassuring as the patient has been disease-free four years postexcision.

The Effect of Patient Positioning on Intraoperative Neuromonitoring During Thyroid and Parathyroid Surgery.

Intraoperative neuromonitoring (IONM) has been accepted as a routine adjunct among surgeons who perform thyroid and parathyroid surgeries. Thyroid and parathyroid surgeries use various patient positioning strategies that have poorly understood effects on IONM. The aim of this study was to compare IONM signals between the transaxillary and transcervical approaches. In this retrospective cohort study, we evaluated 463 adult patients who underwent a total of 502 procedures. The procedures performed included total thyroidectomy, right or left hemithyroidectomy, and parathyroidectomy. Vagus nerve and recurrent laryngeal nerve (RLN) latency and amplitude measurements were analyzed intra-operatively. The distances between the vagus nerve and the trachea were measured via ultrasound during transaxillary procedures. Compared to the transcervical approach, the right vagus nerve latency was significantly decreased in the transaxillary approach. Transaxillary surgery was not associated with increased latency or decreased amplitude on IONM. The distance between the vagus nerve and trachea was significantly decreased post-positioning during transaxillary approaches. Despite differences in patient positioning, a transaxillary approach was not associated with increased stress on the vagus nerve or RLN, according to IONM data. The decreased right vagus nerve latency associated with a transaxillary approach highlights the importance of considering patient positioning and laterality while interpreting IONM data.

Trans-oral endoscopic endocrine surgery vestibular approach: Pioneering the technique in the Gulf Cooperation Council Countries – A case series

BackgroundWe present our experience with the first five thyroidectomies and parathyroidectomy in Kuwait performed via the transoral endoscopic vestibular approach. MethodsRetrospective data collection for all trans-oral endoscopic vestibular approach endocrine surgeries performed at a single institution in Kuwait between November 2019 and February 2021. Information on patient demographics, perioperative management and complications were collected and reviewed. OutcomesAll 5 cases were completed successfully; the intended specimen was extracted successfully via the trans-oral endoscopic vestibular approach and conversion to traditional trans-cervical approach (TCA) was not required. Operative time for the parathyroidectomy case was 225 min and the average operative time for the remaining 4 cases, thyroidectomies, was 151 min. Blood loss was minimal, and length of hospital stay was between 24 and 48 h. One patient had a transient mental nerve injury, and one patient experienced a postoperative seroma which required aspiration. One case required completion thyroidectomy as histopathology revealed papillary thyroid carcinoma. ConclusionTransoral vestibular approach is a scar free and safe approach to thyroidectomies and parathyroidectomies. Careful patient selection and counselling with regards to risk versus benefit is required. It is an excellent alternative to the traditional transcervical approach and offers great cosmetic results.

A case report of a huge euthyroid goiter with retrosternal extension

Massive goiter with retrosternal extension is most frequently found in the anterior mediastinum; however, 10%–15% of the cases are found in the posterior mediastinum. It may induce symptoms caused by tracheal, esophageal, and recurrent laryngeal nerve compression. Surgery for such a huge mass requires a high degree of experience to avoid serious complications, particularly if it weighs >500 g. Herein, we report the case of a 64-year-old man who complained of neck swelling which was gradually increasing in size during the past 19 years and breathing difficulty that worsened during the past years. A 31 × 16 cm heterogeneous enhancing mass that expanded the thyroid gland with retrosternal extension, pushing the main vessels posterolaterally and compressing the trachea, was detected during computed tomography of the neck and chest. Total thyroidectomy was performed safely via a transcervical approach. The recovery period was uneventful, and the patient was discharged 5 days later. Given the rarity of a massive goiter that pushes the main vessels and compresses the trachea in the posterior mediastinum, this case report emphasizes the treatment options and outcome of this condition.

Intrafollicular oocyte transfer (IFOT): Potential feasibility in the ovine species

Intra-follicular oocyte transfer (IFOT) is a promising and innovative technique for in vivo embryo production previously described for equines and bovines. The aim of this study was to assess the feasibility of IFOT in the ovine species. Two preliminary in vivo and in vitro trials were performed to test the optimal procedures and timing for IFOT. In the in vivo trial, follicular growth was monitored with transrectal ultrasonography in ten adult ewes to preliminarily determine the ovulation and ideal timing for IFOT. The in vitro trial assessed i) the optimal inner diameter of the injection needle and ii) the recovery rate and integrity of injected cumulus-oocyte complexes (COCs) after follicle aspiration. For IFOT and embryo collection, five ewes were synchronized by CIDR insertion. Forty hours after CIDR removal, in ewes under sedation and general anesthesia, the ovaries were exposed by laparotomy, and the preovulatory follicle was injected with COCs previously collected from ovaries obtained from an abattoir. At 4 h after surgery, fully recovered ewes were housed in a paddock with a ram of proven fertility. Crayon marking on ram's chest was used to detect mating. Ovulation was assessed 40 h after the transfer of oocytes by transrectal ultrasonography. On day 6 after IFOT, embryo collection was performed by uterine flushing. In the in vitro testing, injection of >5 mm follicles with a 28 G needle loaded with 30 COCs in a 5 μL volume resulted in higher recovery rates and better preservation of COCs integrity. In the in vivo trial, ultrasound scanning revealed that ovulation occurred between 60 and 72 h after CIDR removal in all animals. In one ewe subjected to IFOT, 22/24 oocytes were effectively injected into the preovulatory follicle, but no embryos were collected after flushing. In the remaining four animals, 85/102 oocytes were injected, and six cleaved embryos, 12 morulae and 1 blastocyst were collected, including native embryos. This preliminary investigation indicated that IFOT in ovine species resulted in ovulation, fimbrial capture, tubal transport of heterologous oocytes and in vivo embryo production. Further studies are needed to optimize the embryo recovery rate and develop less invasive techniques for oocyte injection and uterine flushing, such as through a laparoscopic or transcervical approach.

Simplifying the Surgical Classification and Approach to the Posterolateral Skull Base and Jugular Foramen Using Anatomical Triangles.

IntroductionLesions of the jugular foramen (JF) and postero-lateral skull base are difficult to expose and exhibit complex neurovascular relationships. Given their rarity and the increasing use of radiosurgery, neurosurgeons are becoming less experienced with their surgical management. Anatomical factors are crucial in designing the approach to achieve a maximal safe resection.Methods and methodsSix cadaveric heads (12 sides) were dissected via combined post-auricular infralabyrinthine and distal transcervical approach with additional anterior transstyloid and posterior far lateral exposures. Contiguous surgical triangles were measured, and contents were analyzed. Thirty-one patients (32 lesions) were treated surgically between 2000 and 2016 through different variations of the retro-auricular distal cervical transtemporal approaches.ResultsWe anatomically reviewed the carotid, stylodigastric, jugular, condylar, suboccipital, deep condylar, mastoid, suprajugular, suprahypoglossal (infrajugular), and infrahypoglossal triangles. Tumors included glomus jugulare, lower cranial nerve schwannomas or neurofibromas, meningiomas, chondrosarcoma, adenocystic carcinoma, plasmacytoma of the occipitocervical joint, and a sarcoid lesion. We classified tumors into extracranial, intradural, intraosseous, and dumbbell-shaped, and analyzed the approach selection for each.ConclusionJugular foramen and posterolateral skull base lesions can be safely resected through a retro-auricular distal cervical lateral skull base approach, which is customizable to anatomical location and tumor extension by tailoring the involved osteo-muscular triangles.

Approach to a Sewing Needle in the Parapharyngeal Space: A Case Report

ABSTRACT
 Objective: To describe a unique situation of a sewing needle lodged in the parapharyngeal space and elucidate the problems encountered in its successful removal.
 Methods:
 Design: Case Report
 Setting: Tertiary Private Hospital
 Patient: One 
 Result: A 24-year-old male tailor accidentally swallowed a sewing needle that pierced the oropharyngeal wall and was wedged in the parapharyngeal space. After a thorough physical examination, 70 degree rod endoscopy, radiography and doppler ultrasonography and intraoperative C-arm X-ray for intraoperative localization and as a guide for extraction all yielded less than optimal guidance. Although an intra-oral approach was initially taken, the transcervical approach provided the best access.
 Conclusion: Removal of a sharp foreign body in the parapharyngeal space should be considered a surgical emergency owing to its close proximity to vital structures and the potential for serious complications. Identifying the exact location may require a variety of imaging modalities, and foreign body extraction may entail multiple surgical approaches.

Surgical management of parapharyngeal lymph node metastases from thyroid carcinoma with transcervical approach

BackgroundParapharyngeal lymph node metastasis is very rare in patients with thyroid carcinoma. In this study, we elucidated on the clinical features, diagnosis, surgical treatment, and outcomes for patients with parapharyngeal lymph node metastases from thyroid carcinoma. MethodsPatients with thyroid carcinoma who had been subjected to surgery through the transcervical approach at our institution between April 1999 and January 2019 were retrospectively enrolled in this study. ResultsParapharyngeal lymph node metastases were successfully resected through the transcervical approach in all the 97 patients. There were 32 treatment-naïve patients, while 65 patients had a history of treatment before parapharyngeal lymph node metastases. All 97 cases of parapharyngeal lymph node metastases were detected by enhanced CT scans. Lateral neck lymph nodes metastases were confirmed in 96 patients. Unexpected postoperative neurological side effects were reported in 11 (11%) patients, including dysphagia in 5 (5%) patients, Horner’s syndrome in 2 (2%) patients, glossal deviation in 3 (3%) patients, and asymmetrical mouth in 1 (1%) patient. During the follow-up period, 6 of the 97 patients exhibited parapharyngeal lymph node recurrence (recurrence rate 6.2%). The incidence of distant metastases was 44.3% (43 out of 97). The 5- and 10-year disease-specific survival was 93.4% and 88.9%, respectively. ConclusionParapharyngeal lymph node metastases should be considered in patients with widespread cervical lymph node metastases. Enhanced CT scan is one of the best methods for diagnosing such metastases. Surgical resection through the transcervical approach is an effective and safe option for patients with parapharyngeal lymph node metastases from thyroid carcinoma. Moreover, parapharyngeal lymph node metastasis is associated with distant metastases that may lead to poor prognosis.

Extra-oral approach to lower third molar: a rare surgical indication.

The avulsion of the impacted lower third molar is one of the most common procedures in oral surgery. Even though it is characterized by possible complications due to the lesion of lingual and inferior alveolar nerves, the intra-oral surgical approach represents the first-choice strategy when planning surgery. However, in case of ectopic tooth in the mandibular basal bone, it is appropriate to consider an extra-oral transcutaneous surgical approach. The ectopia of the inferior wisdom tooth represents a very rare clinical condition and sometimes it is even unknown by patients and dentists: further evidence of this fact is represented by the paucity of paper related to the topic that can be found in the international scientific literature. The experience of the Department of Maxillofacial Surgery of San Gerardo Hospital in Monza (Italy) in management and treatment of ectopic impacted lower third molar is exposed through the presentation of three cases of ectopic third molar. Two out of three patients, aware of the risks related to the surgical procedure, refused the treatment proposed. One patient underwent surgical avulsion of the wisdom tooth through extra-oral transcervical approach. No early or late complications have been observed. Extra-oral surgical approach for ectopic lower third molar should be considered for selected cases. Given the rarity of the clinical condition and the procedure-related risks, accurate preoperative information has to be provided to the patient by physician and the procedure should only be performed by expert and competent surgeons.

190 THE USEFULNESS OF A BILATERAL TRANS-CERVICAL PNEUMOMEDIASTINAL APPROACH FOR MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY

Abstract Several authors have reported on the left trans-cervical and transhiatal approaches under pneumomediastinum and right cervical open surgery for mediastinoscopic esophagectomy. However, with these approaches, sufficient dissection of the right upper mediastinal paraesophageal lymph nodes, right recurrent nerve lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes is thought to be difficult. We herein report the usefulness of the ‘bilateral’ trans-cervical pneumomediastinal approach. Methods Ten patients with thoracic esophageal cancer were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach. After this approach, thoracoscopic observation was then performed in the left decubitus position, and if the lymph nodes were not sufficiently dissected, the remnant lymph nodes were retrieved thoracoscopically. Results The average total number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average total number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without the right trans-cervical pneumomediastinal approach, roughly four of the right cervical and upper mediastinal paraesophageal lymph nodes and one or two of the subaortic arch to the left tracheobronchial lymph nodes could not have been retrieved. Conclusion A bilateral trans-cervical pneumomediastinal approach is useful for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

Management of parapharyngeal space tumors with transparotid–transcervical approach: analysis of prognostic factors related with disease-control and functional outcomes

Different therapeutic strategies have been developed to improve surgical and functional outcome of parapharyngeal space (PPS) neoplasms. The transparotid-transcervical approach (TTa) is a valid surgical option to manage most PPS tumors. Its short- and long-term disease control and cranial nerve (c.n.) function outcomes have not been discussed extensively. All patients who underwent TTa over a 10-year period at a tertiary academic center were retrospectively reviewed. Data about preoperative imaging, clinical presentation, tumor's size, location and histology, and postoperative oncological and functional results were registered and analyzed. Sixty patients matched the inclusion criteria. Most of the lesions were benign (71.7%), involved the prestyloid PPS (63.3%) and measured more than 30mm (75%). Fifty-two (86.7%) lesions were resected en-bloc. Clear margins were achieved in 91.7% of the cases, with positive margins solely associated with malignancy (p = 0.008). Post-operative c.n. function was satisfactory, with X c.n. function significantly associated with the retrostyloid location (p = .00) and neurogenic tumors (p = 0.02). Local disease-control was achieved in 96% of the cases after a median follow-up of 46 (± 19.7-82.0 IQR) months. The TTa was safe and effective, achieving a satisfactory local control rate. Nevertheless, malignancies maintain a higher rate of positive margin due to their infiltrative nature and the complex anatomy of the PPS. In such cases, multiportal approaches might be more effective. However, post-operative c.n. function remained satisfactory, irrespective of lesions' size and histopathologic behavior. A higher X c.n. deficit rate was observed in retrostyloid and neurogenic lesions.

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy.

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Parapharyngeal carcinosarcoma treated with an endoscopic-assisted transcervical approach: a case report

: Primary tumors of the parapharyngeal space (PPS) are very rare, accounting for approximately 0.5–1.5% of all head and neck tumors. Most of them are benign lesions (80%) and pleomorphic adenoma is the most common, followed by neurogenic tumors. Multiple surgical approaches have been described, each one offering various functional outcomes, and the transcervical approach still represents the workhorse for head and neck surgeons confronting the PPS. Large tumors, or those located in the upper part of PPS, often require greater mobilization of neural and vascular structures, or combined routes with a mandibulotomy or an infratemporal fossa approach, therefore associated with considerable morbidity. In the present study we report the case of an 81-year-old woman with persistence of a PPS malignant tumor, after radiation treatment. A surgical resection via an endoscopic-assisted transcervical approach was performed. Complete tumour removal was obtained. No intra-, peri- or post-operative complications were reported. Histopathological findings were consistent with salivary carcinosarcoma. Routinely, PPS tumors are removed through the transcervical approach. Recently, several surgical minimal invasive approaches to PPS have been described, employing endoscopic and robotic assistance via transnasal and transoral windows. The endoscopic-assisted transcervical approach PPS allowed us to remove the tumor in conditions of good visualization, preventing neurovascular injuries and tumor spillage.

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.

Current Therapeutic Approaches to Subglottic Stenosis in Patients With GPA: A Systematic Review.

The management of subglottic stenosis (SGS) in granulomatosis patients with polyangiitis (GPA) has no clear guidelines. This systematic review aimed to identify different surgical techniques and evaluate the outcomes of applied procedures. An electronic search was performed using 3 major databases, CINAHL, PubMed, and Clinical key, to include relevant studies published from the databases from inception through January 2017. All primary studies reporting treatment of SGS in cases with GPA were included. Articles were excluded if not relevant to the research topic or if they were duplicates, review articles, editorials, short comments, unpublished data, conference abstracts, case reports, animal studies, or non-English studies. Thirteen papers were included in our systematic review with a total of 267 cases for the qualitative review Endoscopic approaches showed favorable outcomes with the need to use multiple procedures to achieve remission. The open transcervical approach showed excellent results mainly after failure of other endoscopic techniques. Tracheostomy was necessary for severe respiratory obstruction symptoms. Medical treatment was essential for stabilizing the active disease and therefore may enhance the success rate postoperatively. Subglottic stenosis in patients with GPA requires a multidisciplinary approach to provide optimal management regarding disease activity, grade of stenosis, and severity of symptoms.

Balloon-Assisted Rib Graft Placement in Endoscopic Posterior Cricoid Split Procedure.

View Video S1 Laryngoscope, 132:212–214, 2022

Radical minimally invasive esophagectomy for esophageal cancer via transcervical and transhiatal approaches: a narrative review.

ObjectiveMinimally invasive esophagectomy (MIE) has been widely applied for the treatment of esophageal carcinoma. It is much less invasive, as it avoids employing a transthoracic procedure.BackgroundMIE via transcervical and transhiatal approaches has been adopted in our center. In this approach, with the assistance of single-port techniques or robotic-assisted surgical systems, the esophagus is mobilized under visualization, which is followed by the removal of esophageal and mediastinal lymph nodes.MethodsIncreasing the surgical space by mediastinal insufflation or by elevation of the sternum with a hook may improve intraoperative identification of tissues and facilitate intraoperative mobilizations. The procedure can be performed simultaneously via both cervical and abdominal approaches without the need for intraoperative turning of the patient, which shortens the operative time. Also, there is no need for thoracotomy or single-lung ventilation, which avoids disturbance to the respiratory and circulation systems.ConclusionsSuitable instruments, especially state-of-the-art energy instruments, facilitate surgical separation and hemostasis. This surgical procedure has become increasingly sophisticated over the past decade, and its modular operation has been widely recognized. The feasible place of the neck-esophageal hiatus rendezvous is on the left main bronchus around the subcarinal region. Here we describe the technical features, key steps, and necessary precautions of this minimally invasive surgery for esophageal carcinoma.

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.