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Transcarotid Artery Revascularization In High Risk Patients: Lessons Learned
Adeola T. Odugbesi, MD, Maen Aboul Hosn.
University of Iowa, Iowa City, IA, USA.

OBJECTIVES:Transcarotid revascularization (TCAR) offers a low risk treatment option in select patients with severe carotid stenosis who also have high risk anatomic and/or physiologic characteristics. We reviewed a single institution analysis of TCAR performed in patients considered high risk candidates for standard carotid endarterectomy.
METHODS: 40 patients underwent TCAR between March 2018 and September 2019. 20% (n=8) were performed under general anesthesia and 80% (n=32) under cervical block. 15% (n=6) were symptomatic and 85% (n=34) were asymptomatic. The indications for the procedure included high cervical lesions (n=13), recurrent stenosis following carotid endarterectomy (n=9), critical stenosis following neck radiation (n=6), history of neck dissection (n=4), recurrent stenosis following transfemoral stenting (n=3), symptomatic carotid dissections (n=2), high medical risk (n=3). 4 patients had tracheostomies for head and neck malignancies. Two patients underwent proximal carotid and innominate artery stenting in the same setting.
RESULTS: All procedures were successfully performed successfully. Two patients required carotid patching at the site of access. In patients with tracheostomies, special prepping and draping techniques were utilized to avoid contamination. The average operating time was 86.4 minutes (range 50-153) and average clamp time was 14.6 minutes (range 7-30). Protamine was not used for reversal in any of the patients. All patients were discharged on post-operative day one. There were no documented perioperative or 30-day incidences of stroke, cranial nerve injury, major bleeding, infection, MI or death. Patient follow up ranged from 3 to 18 months. Carotid duplex scans immediately following surgery and at one month post operatively showed complete resolution of stenosis in all patients.
CONCLUSIONS: TCAR can be safely utilized in patients with more complex carotid lesions and hostile neck anatomy, including those with tracheostomies and extensive neck radiation as well as those with extensive medical comorbidities.


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