Difference between revisions of "Transcarotid Artery Endovascular Revascularization"
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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). | 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). | ||
Goal: Restoring laminar blood flow through a stenotic carotid artery narrowed by atherosclerotic or neointimal hyperplastic disease. | |||
== Overview == | == Overview == | ||
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=== Indications: === | === Indications: === | ||
Stent placement is preferred to carotid endarterectomy if the patient have ANY of a number of comorbid medical disease or anatomical factors (see below) that would complicate the hemodynamic management intraoperatively putting the patient at elevated risk for CV complications (hemodynamic instability / vasoplegia, MI, stroke, arrhythmia, etc) or surgical/airway access. | |||
Medical: | Medical: | ||
* Age > 75 | * Age > 75 | ||
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*Prior head/neck surgery or irradiation | *Prior head/neck surgery or irradiation | ||
* Spinal immobility | * Spinal immobility | ||
* Restenosis post CEA | * Restenosis post carotid endarterectomy (CEA) | ||
* Surgically inaccessible lesion | * Surgically inaccessible lesion | ||
* Laryngeal palsy; Laryngectomy | * Laryngeal palsy; Laryngectomy | ||
| Line 59: | Line 57: | ||
== Preoperative management == | == Preoperative management == | ||
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | === Patient evaluation:<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->=== | ||
Assess for the listed conditions/diseases above. | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
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|- | |- | ||
|Airway | |Airway | ||
| | |Neck mobility, ability to tolerated surgical positioning. Prior neck radiation | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Baseline neurologic exam, post operatively at risk for micro-embolic strokes. Assess if carotid stenosis is symptomatic (see below) | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Exercise tolerance, assess for listed cardiovascular comorbid diseases above | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| | |Exercise tolerance | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| Line 81: | Line 80: | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Ensure taking dual anti-platelet therapy per surgical team's directions | ||
|- | |- | ||
|Renal | |Renal | ||
| | |Current volume status, relative hypovolemia may adversely affect ability to induce HTN during flow reversal | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |Check BG | ||
|- | |- | ||
|Other | |Other | ||
| | | | ||
|} | |} | ||
- Symptomatic Carotid Stenosis: Stroke or TIA referable to the appropriate carotid artery distribution within the previous six months AND carotid stenosis > 50%. | |||
- Asymptomatic Carotid Stenosis: Atherosclerotic narrowing of the extracranial ICA (>80%) without recent stroke or TIA (Of note, vertigo and syncope are not typical manifestations) | |||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
All carotid surgeries are considered high-risk & pre-surgical testing should follow AHA/ACA guidelines for high-risk noncardiac surgery. | |||
* CBC, electrolytes, creatinine, PT/INR/aPTT | |||
* T&C; consider requesting to have 2 units of pRBC on hold | |||
* 12 lead EKG | |||
* Consider Stress Test (exercise or pharmacology) if: | |||
** Poor or unknown functional status | |||
** Calculated risk for major adverse cardiovascular events (MACE) is >1% on the VQI or NSQIP calculator | |||
* TTE if concerned for CHF, pulmonary HTN, or valvular disease (may impair ability to safely induce needed hypertension intraoperatively) | |||
* Per surgical team's preference either CT angiogram v Carotid ultrasound to define anatomy | |||
=== 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 | |||
If planning to use MAC, have supplies for full conversion to GA | |||
Have appropriate vasoactive medication available quickly titrate blood pressure intraoperatively | |||
- Push Medications: consider Nitroglycerin, Epinephrine, Phenylephrine | |||
- Prepared Drips: Norepinephrine (or preferred short acting pressor), can consider supplies for vasodilatory drip in room | |||
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. --> === | ||
=== 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. --> === | ||
Superficial Cervical Plexus Block | |||
- With block procedure can be preformed with MAC | |||
- Benefit in GA cases by decreasing opioid requirement, allows for more rapid neurologic assessment postoperatively | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
- Standard ASA monitors, 5 lead EKG | |||
- Pre-induction arterial line | |||
- 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 | |||
- 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 | |||
=== 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 | |||
=== 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. --> === | ||
| Line 120: | Line 159: | ||
=== 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 | |||
- | |||
== 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). --> == | ||
Revision as of 10:59, 10 November 2022
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| Airway | |
| Lines and access | |
| Monitors | |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative | |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 2 |
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).
Goal: Restoring laminar blood flow through a stenotic carotid artery narrowed by atherosclerotic or neointimal hyperplastic disease.
Overview
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:
Stent placement is preferred to carotid endarterectomy if the patient have ANY of a number of comorbid medical disease or anatomical factors (see below) that would complicate the hemodynamic management intraoperatively putting the patient at elevated risk for CV complications (hemodynamic instability / vasoplegia, MI, stroke, arrhythmia, etc) or surgical/airway access.
Medical:
- Age > 75
- Congestive Heart Failure
- LVEF < 35%
- >2 diseased coronaries w/ 70% stenosis
- Unstable angina or abnormal stress test
- MI within 6 weeks
- Need for additional open heart surgery
- Need for major surgery (including vascular)
- Uncontrolled diabetes
- Severe pulmonary disease
Anatomic:
- Prior head/neck surgery or irradiation
- Spinal immobility
- Restenosis post carotid endarterectomy (CEA)
- Surgically inaccessible lesion
- Laryngeal palsy; Laryngectomy
- Permanent contralateral cranial nerve injury
- Contralateral occlusion
- Severe tandem lesions
- Bilateral stenosis requiring treatment
Preoperative management
Patient evaluation:
Assess for the listed conditions/diseases above.
| System | Considerations |
|---|---|
| Airway | Neck mobility, ability to tolerated surgical positioning. Prior neck radiation |
| Neurologic | Baseline neurologic exam, post operatively at risk for micro-embolic strokes. Assess if carotid stenosis is symptomatic (see below) |
| Cardiovascular | Exercise tolerance, assess for listed cardiovascular comorbid diseases above |
| Pulmonary | Exercise tolerance |
| Gastrointestinal | |
| Hematologic | Ensure taking dual anti-platelet therapy per surgical team's directions |
| Renal | Current volume status, relative hypovolemia may adversely affect ability to induce HTN during flow reversal |
| Endocrine | Check BG |
| Other |
- Symptomatic Carotid Stenosis: Stroke or TIA referable to the appropriate carotid artery distribution within the previous six months AND carotid stenosis > 50%.
- Asymptomatic Carotid Stenosis: Atherosclerotic narrowing of the extracranial ICA (>80%) without recent stroke or TIA (Of note, vertigo and syncope are not typical manifestations)
Labs and studies
All carotid surgeries are considered high-risk & pre-surgical testing should follow AHA/ACA guidelines for high-risk noncardiac surgery.
- CBC, electrolytes, creatinine, PT/INR/aPTT
- T&C; consider requesting to have 2 units of pRBC on hold
- 12 lead EKG
- Consider Stress Test (exercise or pharmacology) if:
- Poor or unknown functional status
- Calculated risk for major adverse cardiovascular events (MACE) is >1% on the VQI or NSQIP calculator
- TTE if concerned for CHF, pulmonary HTN, or valvular disease (may impair ability to safely induce needed hypertension intraoperatively)
- Per surgical team's preference either CT angiogram v Carotid ultrasound to define anatomy
Operating room setup
TCAR can be preformed under GA or MAC with regional anesthesia
If planning to use MAC, have supplies for full conversion to GA
Have appropriate vasoactive medication available quickly titrate blood pressure intraoperatively
- Push Medications: consider Nitroglycerin, Epinephrine, Phenylephrine
- Prepared Drips: Norepinephrine (or preferred short acting pressor), can consider supplies for vasodilatory drip in room
Run lines & monitors outside of fluoroscopy path to optimize surgical field
Patient preparation and premedication
Regional and neuraxial techniques
Superficial Cervical Plexus Block
- With block procedure can be preformed with MAC
- Benefit in GA cases by decreasing opioid requirement, allows for more rapid neurologic assessment postoperatively
Intraoperative management
Monitoring and access
- Standard ASA monitors, 5 lead EKG
- Pre-induction arterial line
- 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
- Intraoperative ACT monitoring during heparinization (target 250-350; verify goal with surgical team)
Induction and airway management
If planning on MAC with natural airway & superficial cervical plexus block, consider sedation with remifentanil infusion
Positioning
Supine with head turned contralateral to site of planned procedure
Maintenance and surgical considerations
Emergence
Postoperative management
Disposition
Pain management
Potential complications
- Micro-embolic stroke; check neurologic exam
-
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | Supine | |
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
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.
3.) Silk Road Medical. TCAR surveillance project. Accessed January 1, 2020. https://silkroadmed.com/tcar-surveillance-project/