Simultaneous Treatment Of Symptomatic Cervical And Tandem Intracranial Carotid Lesions Using Transcarotid Artery Revascularization (TCAR)
Alireza Daneshpajouh, DO1, Rana El-Tawil, MD1, Ahmed K. Ghamraoui, DO2, Joseph J. Ricotta, MD, MS, DFSVS, FACS1
1Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, 2Florida Atlantic University Charles E. Schmidt College of MedicineDelray Medical Center, Boca Raton, FL
DEMOGRAPHICS: 75-year-old male with a past medical history of peripheral artery disease, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, and atrial fibrillation presented with recurrent left hemispheric cerebrovascular accident (CVA).
HISTORY: Three months prior to presentation, he underwent balloon angioplasty of the left intracranial internal carotid artery (ICA) for an acute CVA through a transfemoral approach which was complicated by a femoral pseudoaneurysm requiring open surgical repair. He later presented with acute right-sided weakness and facial droop. Computed tomography revealed severe stenosis of the cervical ICA as well as the petrous and cavernous intracranial ICA, and severe atherosclerotic disease of the aortic arch.
PLAN: Given his multiple risk factors and severely diseased aortic arch, a left-sided TCAR procedure was planned to simultaneously treat both his severe cervical carotid stenosis and tandem intracranial carotid lesion. A venous sheath was placed in the right femoral vein. A supraclavicular incision was made between the sternal and clavicular heads of left sternocleidomastoid muscle. The common carotid artery (CCA) was dissected free and a sheath was placed in proximal CCA. An arteriogram demonstrated >80% stenosis of the distal CCA and proximal ICA as well as the petrous and cavernous portions of the intracranial carotid artery. The ENROUTETM flow reversal system was connected between the left carotid artery and right femoral vein. The cervical carotid artery lesion was dilated with balloon angioplasty and stented with a self-expanding stent. Post-treatment angiography demonstrated stent patency with no residual stenosis. Flow reversal was continued and using the carotid sheath, balloon angioplasty and stenting was performed successfully treating the intracranial stenosis. Flow reversal was discontinued, the access sheath was removed and the carotid arteriotomy was closed.
DISCUSSION: Symptomatic tandem intra- and extracranial carotid lesions are a common yet perplexing finding especially in patients with hostile anatomical disease burden at high-risk for embolization and complication. There is debate as to which lesion should be primarily treated (Intracranial first vs. extracranial first). Simultaneous treatment of cervical and intracranial ICA disease via the TCAR approach is a viable option for the treatment of tandem carotid stenoses and potentially minimizes risks associated with the transfemoral approach. To our knowledge, this represents the first reported case using TCAR to simultaneously treat symptomatic intracranial and extracranial carotid stenoses
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