Transcervical approach with protective flow reversal for carotid angioplasty and stenting

Purpose: To report our initial experience using a transcervical approach for carotid angioplasty/stenting (CAS) that employs internal carotid artery (ICA) flow reversal for neuroprotection. Methods: Seventeen patients (15 men; mean age 65 years, range 49-77) with significant carotid stenosis (mean 88%, 8 symptomatic) were treated with protected transcervical CAS. Eleven patients were considered at high risk for carotid endarterectomy; 8 were also considered high risk for transfemoral access (unfavorable aortic arch anatomy or advanced aortoiliac occlusive disease). Anesthesia was based on patient and anesthesiologist preferences. The approach consisted of a 2-cm cutdown over the common carotid artery and placement of a 9-F sheath. ICA flow was reversed and shunted into the jugular vein during the carotid intervention. Results: Access and carotid stenting were successful in all cases. Thirteen procedures were performed under general and 4 under local anesthesia. Mean flow reversal time was 34±4 minutes (25 minutes in the last 7 cases). The patients tolerated the procedure well and had no neurological events. Four (23%) patients had significant oozing from the operative site; 2 developed small neck hematomas that were treated conservatively. All patients were discharged on the first postoperative day. There were no deaths, changes in neurological status, or restenosis over a mean follow-up of 12 months (range 1-24). Conclusions: Our initial experience demonstrates that a transcervical approach is a viable alternative for CAS. The procedure can be performed safely, with good initial clinical outcomes. The approach allows carotid flow reversal and emboli protection without introducing neuroprotection devices. The method appears best suited for patients at high risk for endarterectomy and transfemoral access.