Transcarotid Artery Revascularization In Patients With Neck Radiation Or Tracheostomy
Anna Marjan, MD, Maen Aboul Hosn.
University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
OBJECTIVES: Transcarotid artery revascularization (TCAR) has been shown to be an effective treatment modality in high risk patients with carotid artery stenosis. A subset of patients with anatomic high-risk criteria include those who have undergone neck irradiation and radical neck dissection. Some of these patients require a tracheostomy which presents a source of potential contamination and further complicates the surgery. We present a case series of eight patients who have undergone TCAR after undergoing neck radiation or tracheostomy.
METHODS: We present seven patients with a history of oropharyngeal cancer who had received either neck radiation alone or in conjunction with total laryngectomy and tracheostomy. All patients were found to have severe carotid artery stenosis with one patient having bilateral severe stenosis. 50% of patients (4/8) were symptomatic on presentation with symptoms ranging from transient ischemic attacks to stroke. All patients underwent pre-operative carotid duplex scans followed by CT angiogram of the neck and were started on a pre-operative medical regimen consisting of aspirin, clopidogrel, and a statin. All patients underwent TCAR using the EnRoute Neuroprotection System (NPS; Silk Road Medical Inc, Sunnyvale, CA). Perioperative antibiotics were administered to all patients.
RESULTS: Eight TCAR procedures were successfully performed with one patient receiving bilateral procedures. The procedure was performed under monitored sedation and local anesthesia in seven cases while general anesthesia was used in one case. The average operating time was 101 minutes (range 86-151) and average clamp time was 17.25 minutes (range 9-28). Protamine was not used for reversal in any of the patients. All patients were discharged on post-operative day one. There were no episodes of cranial nerve injury, intraoperative or post-operative stroke, myocardial infarction, or death. Patient follow up ranged from three months to one year. All patients successfully healed from surgery without evidence of infection. Post operative carotid duplex scans showed complete resolution of stenosis in all patients (ranging from 0% to less than <50%).
CONCLUSIONS: This case series shows that patients with a hostile neck due to radiation, radical neck dissection, and tracheostomy can be effectively treated with TCAR. Although the history of neck radiation and proximity of a contaminated tracheostomy site can both potentially increase the risk of infection, this risk can be minimized with proper prepping, draping and dissection techniques.
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