Cerebral Perfusion Optimization With Transcranial Doppler Monitoring During Transcarotid Artery Revascularization
Samuel B. Booth, Shashank Sharma, MD, Zsolt Garami, MD, Charudatta Bavare, MD, FACS, Maham Rahimi, MD, PHD.
Houston Methodist, Houston, TX, USA.
DEMOGRAPHICS: Transcarotid artery revascularization (TCAR) has shown promise in treating patients with contralateral chronic occlusions; however, the flow reversal strategy remains unknown. Intraoperative transcranial doppler (TCD) provides unique insight to cerebral hemodynamics allowing immediate recognition and intervention for ischemia. HISTORY: A 72-year-old man with history of neck radiation for basal cell carcinoma was transferred to our ICU after tPA administration for right hemispheric stroke. Imaging revealed right ICA occlusion and severe left ICA stenosis for which we were consulted. After multidisciplinary conversation with the Neurology team, the decision was made to intervene on the left ICA to preserve the ischemic penumbra. PLAN: Intraoperatively the left CCA and right femoral vein were accessed in standard fashion. After clamping of the CCA, the TCD noted adequate antegrade flow; however, with initiation of high-flow reversal there was no flow noted in the MCA. The CCA was then unclamped and re-clamped, this time with low-flow setting after which TCD revealed adequate antegrade perfusion. The remainder of the procedure was uneventful, and the patient recovered without any further neurologic sequelae. DISCUSSION: As TCAR expands, nuances to reversal strategies need to be better delineated. This case emphasizes the importance of intensive neuromonitoring such as TCD during TCAR. The real-time detection of absent ipsilateral flow with TCD monitoring allowed for an immediate switch from high to low-flow reversal, avoiding intraoperative ischemia. 
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