Transcarotid Artery Revascularization

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Presentation transcript:

Transcarotid Artery Revascularization Technique : Preventing Dissection Complications Dr.Raghu Motaganahalli MD FRCS FACS Associate Professor of Surgery Division of Vascular Surgery Indiana University School of Medicine

Disclosures Consultant- Silk Road Medical inc . Teaching , Proctor- Do not receive any direct remuneration

Emerging Role for TCAR TCAR has emerged as an alternative option for carotid revascularization Early results from single center , Multicenter, outcomes using VQI data base (TCAR- Surveillance Project ) , Clinical trials ( Roadster-1, Roadster-2 ) have consistent results Superior to CAS in terms of Stroke Comparable results to those derived from CEA Reduced length of procedure, contrast use, Low risk for cranial nerve injuries J Vasc Surg 2015;62:1227-35.

CCA- Dissection Rates- ROADSTER1 Study R1 Site Reported (12/286) R1 Plus Core Lab (21/286) All 4.2% 7.3% Serious 2.1% Convert to CEA 0.3% Note: Conversion to CEA is a sub-set of serious dissections.

Optimizing Results from TCAR Technical success hinges upon obtaining a safe and secure access to common carotid artery Acceptable CCA = Stable sheath placement Stable sheath = robust flow reversal Robust flow reversal = Embolic protection Embolic protection = reduced risk of stroke J Vasc Surg 2015;62:1227-35.

Anatomical Considerations CCA Evaluation

Anatomical Considerations

Additional Tips for Technical Success Choose incision you are comfortable with Vertical or horizontal incision Adequate heparinization – Anticoagulate when you start exposure of CCA Accessing the common carotid artery – Fresh needle, marker wire, micro sheath Vascular control – Umbilical tape v/s vessel loop v/s Clamp Stabilizing the vessel during access Sustained counter traction when inserting sheath No tourniquets

Additional Tips for Technical Success Adequate Pre dilatation Appropriate stent size selection DAPT – Pre and Post Procedure Intra op hemodynamics – Atropine and Glycopyrolate Continue Active and Passive flow reversal after procedure Ensure no air embolization during the injections Protamine at the completion of the procedure

What if you dissect the CCA ? What if you end up in dissection Abandon the access if only a micro sheath and re access the vessel fresh Getting back to true lumen and maintain a wire access Stent across the dissection When you cannot get back to true lumen- open conversion

Summary Dissection of CCA is unique , unusual complication for TCAR Limits technical success Mitigated by proper patient selection, attention to details during sheath placement Be prepared to manage dissection complication by additional stent placement