Transcarotid Artery Endovascular Revascularization - Revision history

Gassy doc: typo

2023-01-10T01:18:04Z

typo

← Older revision		Revision as of 18:18, 9 January 2023
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	General indications for carotid revascularization for stenotic atherosclerotic lesions are the same, regardless of revascularization approach (CEA, TF-CAS, TCAR).		General indications for carotid revascularization for stenotic atherosclerotic lesions are the same, regardless of revascularization approach (CEA, TF-CAS, TCAR).

	- Asymptomatic Carotid Stenosis: Atherosclerotic narrowing of the extracranial ICA of 80-99% without recent stroke or TIA & with life expectancy of >5years. Of note, asymptomatic chronic ~~compete~~ (100%) occlusion not managed with revascularization procedures.		- Asymptomatic Carotid Stenosis: Atherosclerotic narrowing of the extracranial ICA of 80-99% without recent stroke or TIA & with life expectancy of >5years. Of note, asymptomatic chronic complete (100%) occlusion not managed with revascularization procedures.

	- Symptomatic Carotid Stenosis: Stroke or TIA referable to the appropriate carotid artery vascular distribution within the previous six months AND carotid stenosis > 50%.. Ideally revascularization within 2 weeks of symptom onset.		- Symptomatic Carotid Stenosis: Stroke or TIA referable to the appropriate carotid artery vascular distribution within the previous six months AND carotid stenosis > 50%.. Ideally revascularization within 2 weeks of symptom onset.

Ajaksic1 at 15:42, 11 November 2022

2022-11-11T15:42:03Z

← Older revision		Revision as of 08:42, 11 November 2022
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	\| monitors = Standard, 5 Lead		\| monitors = Standard, 5 Lead
	\| considerations_preoperative = DAPT morning of surgery, beta-blockers, volume status, baseline neuro exam		\| considerations_preoperative = DAPT morning of surgery, beta-blockers, volume status, baseline neuro exam
	\| considerations_intraoperative = - Bradycardia/asystole during carotid balloon inflation		\| considerations_intraoperative = - Bradycardia/asystole during carotid balloon inflation (prevent with glyco)
	- Maintaining SBP goal during flow reversal & monitoring rSO2		- Maintaining elevated SBP goal during flow reversal & monitoring rSO2
	- Cerebral Hyperperfusion after stenting (Maintain SBP goal discussed with surgeon)		- Cerebral Hyperperfusion after stenting deployment (Maintain lowered SBP goal discussed with surgeon)
	\| considerations_postoperative = - Post-Stent hypotension & bradycardia (incr risk for MI, ischemic stroke, stent thrombosis		\| considerations_postoperative = - Post-Stent hypotension & bradycardia (incr risk for MI, ischemic stroke, stent thrombosis
	- Early neurological assessment after extubation and during the immediate postop period		- Early neurological assessment after extubation and during the immediate postop period

Ajaksic1: Finished article, updated citations

2022-11-11T15:40:24Z

Finished article, updated citations

Show changes

Ajaksic1: Need to add citations

2022-11-10T19:32:20Z

Need to add citations

← Older revision		Revision as of 12:32, 10 November 2022
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	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
	TCAR can be preformed under GA or MAC with regional anesthesia		TCAR can be preformed under GA or MAC with regional anesthesia. If planning to use MAC, have supplies for full conversion to GA emergently.

	~~If planning to use MAC, have supplies for full conversion to GA~~		Have appropriate vasoactive medication available quickly titrate blood pressure intraoperatively

	~~Have appropriate vasoactive medication available quickly titrate blood pressure intraoperatively~~		- Push Medications: consider Epi, NE, Phenylephrine, Nitroglycerin, Esmolol, Nicardipine

	- ~~Push Medications~~: consider ~~Nitroglycerin, Epinephrine, Phenylephrine~~		- Prepared Drips: Norepinephrine (or preferred short acting vasopressor) spiked & in line, consider having for vasodilatory drip of choice in room

	~~- Prepared Drips~~: ~~Norepinephrine (or preferred short acting pressor), can consider supplies for vasodilatory drip in room~~		Additional Medications: Heparin & Protamine

	Run lines & monitors outside of fluoroscopy path to optimize surgical field		Run lines & monitors outside of fluoroscopy path to optimize surgical field

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
			- Verify that patient is taking Dual Antiplatelet Therapy (DAPT; Aspirin / Plavix) & a statin for the last 7 days including the morning of surgery. If dose not taken, discuss giving preOP with surgical team

			- Continue home beta-blockers

			- Verify medication that impact BP control or cause refractory hypotension compromising cerebral blood flow on induction or during flow reversal (ARB/ACEi) have not been taken

	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
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	- PIV x 2 (note vasoactive medications will be in PIVs, make sure lines are stable/running well)		- PIV x 2 (note vasoactive medications will be in PIVs, make sure lines are stable/running well)

	- Cerebral oximetry to monitor adequacy of collateral circulation via the Circle of Willis during flow reversal		- Cerebral oximetry to monitor adequacy of collateral circulation via the Circle of Willis during flow reversal; ideally placed and calibrate while patient is awake.

	- Intraoperative ACT monitoring during heparinization (target 250-350; verify goal with surgical team)		- Intraoperative ACT monitoring during heparinization (target 250-350; verify goal with surgical team)

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
	If planning on MAC with natural airway & superficial cervical plexus block, consider sedation with remifentanil infusion		- If planning on MAC with natural airway & superficial cervical plexus block, consider sedation with remifentanil infusion.

			GA: Slow controlled induction, goal to maintain BP at baseline to prevent decreased cerebral perfusion

	=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
	Supine ~~with~~ head turned ~~contralateral to~~ site ~~of planned procedure~~		- Supine, neck extended, shoulder roll, head turned away from surgical site

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
			TIVA/Balanced anesthetic/inhalational anesthetic are reasonable

			Have clear communication with the surgical team about what stage of the surgery they are in, critical for BP management/patient safety during a TCAR.

			- Surgical Exposure: maintain BP at baseline or slightly higher

			- Carotid Balloon Inflation: Can cause Bradycardia/asystole due to proximity near carotid baroreceptors. Give preventative glycopyrrolate (unless patient has contraindications to having a further elevated HR; baseline HR > 90 or severe CAD)

			- Flow Reversal: Maintain SBP >160 or 20% above baseline SBP to aid perfusion via Circle of Willis. Closely monitor cerebral oximeter (rSO2) during this time.

			- Stent Deployment: Risk for acute cerebral hyperperfusion. Stop vasopressors, have closed loop communication about BP goal with surgical team and give push vasoactive medications as needed to meet goals (commonly SBP 110-140). Not uncommon to require boluses of nitroglycerin/esmolol/nicardipine to achieve this rapidly

			- During Closing, post-stent Hypotension is common due to persistent carotid baroreceptor stimulation and may require vasopressor support to insure adequate cerebral perfusion until hemodynamics stabilize.

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
			- Avoid bucking due to neck incision & carotid artery puncture.

			- Consider remifentanil, dexmedetomidine, or appropriate opioid titration prior to emergence

	== Postoperative management ==		== Postoperative management ==

	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
			- PACU -> IMC for close neurologic and hemodynamic monitoring

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
			- Opioids

			- Regional anesthesia

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
	~~- Micro-embolic stroke; check neurologic exam~~

	-		* Embolic stroke : during exposure or due to insufficient flow reversal
			* Stroke due to hypoperfusion / insufficient collateral flow via Circle of Willis; watershed infarct
			* Bleeding due to catheter dislodgement: higher risk during MAC as opposed to GA
			* Reperfusion injury: ipsilateral ACA/MCA distribution now seeing higher pressure and flow since no longer obstructed by stenotic segment of carotid artery. Stroke like syndrome which can manifest as encephalopathy or unilateral sensory / motor deficits, seizure, or rarely, intracranial hemorrhage

			*

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Ajaksic1 at 18:59, 10 November 2022

2022-11-10T18:59:30Z

Show changes

Ajaksic1 at 13:46, 10 November 2022

2022-11-10T13:46:59Z

← Older revision		Revision as of 06:46, 10 November 2022
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	=== Surgical procedure: ===		=== Surgical procedure: ===
			The common carotid artery (CCA) is exposed via a small incision superior to the clavicle.

			A flexible sheath is inserted into the CCA proximal to the lesion being stented and the distal end (outside the vessel) is connected to a flow reversal system (FRS).

			At the same time the femoral vein is also being accessed either percutaneously or via surgical exposure, and a 2nd flexible sheath is inserted. The extraluminal end of the femoral sheath is attached to the other end of the flow reversal system (FRS).

			Once connected blood flow from the high pressure CCA to the low pressure femoral vein through the FRS. After flow reversal wires are threaded past the lesion, if indicated pre-dilation of the vessel with balloon angioplasty occurs at this time, followed by deployment of the intralumenal stent. The FRS acts as a filter removing any plaques or disrupted intralumenal, decreasing the risk of micro-embolic strokes.

			After successful placement, flow reversal is turned off and blood flow resumes in its normal direction. Sheaths removed and arteriotomy closed.

			Video with overview of steps: TCAR \| TransCarotid Artery Revascularization Procedure Narrated Animation \| Silk Road Medical \| https://www.youtube.com/watch?v=MI2s4rv0dJA

	=== Indications: ===		=== Indications: ===
			Goal restoring laminar blood flow through a stenotic carotid artery narrowed by atherosclerotic or neointimal hyperplastic disease.

	Decision to stent vs open repair depends on level of either surgical or CV risk. Any one of the following qualify a patient for high-risk status :		Decision to stent vs open repair depends on level of either surgical or CV risk. Any one of the following qualify a patient for high-risk status :

	~~Medical Indications:~~		Criter

	* Age > 75		Medical:
	* ~~CHF~~
	* LVEF < 35%		* Age > 75
	* >2 diseased coronaries w/ 70% stenosis		* Congestive Heart Failure
	* Unstable angina		* LVEF < 35%
	* MI within 6 weeks		* >2 diseased coronaries w/ 70% stenosis
	* Abnormal stress test		* Unstable angina or abnormal stress test
	* Need for open heart surgery		* MI within 6 weeks
	* Need for major surgery (including vascular)		* Need for additional open heart surgery
	* Uncontrolled diabetes		* Need for major surgery (including vascular)
	* Severe pulmonary disease		* Uncontrolled diabetes
	* Prior head/neck surgery or irradiation		* Severe pulmonary disease
			Anatomic:

			*Prior head/neck surgery or irradiation
	* Spinal immobility		* Spinal immobility
	* Restenosis post CEA		* Restenosis post CEA
	* Surgically inaccessible lesion		* Surgically inaccessible lesion
	* Laryngeal palsy; Laryngectomy		* Laryngeal palsy; Laryngectomy
	* Permanent contralateral cranial nerve injury		* Permanent contralateral cranial nerve injury
	* Contralateral occlusion		* Contralateral occlusion
	* Severe tandem lesions		* Severe tandem lesions
	* Bilateral stenosis requiring treatment		* Bilateral stenosis requiring treatment

	== Preoperative management ==		== Preoperative management ==
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	\|-		\|-
	\|Position		\|Position
	\|		\|Supine
	\|		\|
	\|-		\|-
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	2.) Ankam A, Kinthala S, Madabhushi P. Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center. Cureus. 2020 Dec 24;12(12):e12250. doi: 10.7759/cureus.12250. PMID: 33505816; PMCID: PMC7822093.		2.) Ankam A, Kinthala S, Madabhushi P. Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center. Cureus. 2020 Dec 24;12(12):e12250. doi: 10.7759/cureus.12250. PMID: 33505816; PMCID: PMC7822093.

			3.) Silk Road Medical. TCAR surveillance project. Accessed January 1, 2020. <nowiki>https://silkroadmed.com/tcar-surveillance-project/</nowiki>
	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]

Ajaksic1: (Just an interval save, wrote this article yesterday & did not save by mistake...trying to not repeat mistake)

2022-11-10T12:58:47Z

(Just an interval save, wrote this article yesterday & did not save by mistake...trying to not repeat mistake)

← Older revision		Revision as of 05:58, 10 November 2022
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	}}		}}

	Also referred to as a TCAR, a transcarotid artery endovascular revascularization is		Also referred to as a TCAR, a transcarotid artery endovascular revascularization is an alternative to carotid endarterectomy for the management of carotid stenosis in patients who are determined to be poor open repair candidates based on high surgical risk or lesion location (distal lesions). Transcarotid artery revascularization (TCAR) is an alternative to trans-femoral stenting and is meant to decrease the risk for micro-embolic strokes through flow reversal through the carotid during stent placement (see below).

	== Overview ==		== Overview ==

	=== ~~Indications~~ ===		=== Surgical procedure: ===

	=== ~~Surgical procedure~~ ===		=== Indications: ===
			Decision to stent vs open repair depends on level of either surgical or CV risk. Any one of the following qualify a patient for high-risk status :

			Medical Indications:

			* Age > 75
			* CHF
			* LVEF < 35%
			* >2 diseased coronaries w/ 70% stenosis
			* Unstable angina
			* MI within 6 weeks
			* Abnormal stress test
			* Need for open heart surgery
			* Need for major surgery (including vascular)
			* Uncontrolled diabetes
			* Severe pulmonary disease
			* Prior head/neck surgery or irradiation
			* Spinal immobility
			* Restenosis post CEA
			* Surgically inaccessible lesion
			* Laryngeal palsy; Laryngectomy
			* Permanent contralateral cranial nerve injury
			* Contralateral occlusion
			* Severe tandem lesions
			* Bilateral stenosis requiring treatment

	== Preoperative management ==		== Preoperative management ==
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	== References ==		== References ==
			1.) Columbo JA, Martinez-Camblor P, O’Malley AJ, et al. Association of Adoption of Transcarotid Artery Revascularization With Center-Level Perioperative Outcomes. ''JAMA Netw Open.'' 2021;4(2):e2037885. doi:10.1001/jamanetworkopen.2020.37885

			2.) Ankam A, Kinthala S, Madabhushi P. Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center. Cureus. 2020 Dec 24;12(12):e12250. doi: 10.7759/cureus.12250. PMID: 33505816; PMCID: PMC7822093.
	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]

Oliviamsutton: Created page with "{{Infobox surgical procedure | anesthesia_type = | airway = | lines_access = | monitors = | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} Also referred to as a TCAR, a transcarotid artery endovascular revascularization is == Overview == === Indications === === Surgical procedure === == Preoperative management == === Patient evaluation