TCAR
From Bay Area Structural Heart Wiki
TRANSCAROTID ARTERY REVASCULARIZATION
- TCAR supplies kept on a cart in sterile core Med Room 4395B outside Hybrid #14
- Silk Road Rep is present during this procedure
- No Injector
- Table at 30 degrees
- C-arm at 90 degrees
- I-Stat & ACT cartridges (Perfusionist room or borrow from IR)
Warning: Make sure Anesthesia has iStat access!
Supplies
Open
- Angio pack
- Micro puncture kit
- Probe cover
- Fluoro drape
- 60cc syringe (for flushing TCAR supplies)
- Inflation device
- Contrast syringes (DN)
- 035 J guide wire (MH)
- Contrast
Standby
- Kumpe
- Bentson guide wire
- Amplatz 1cm tip
- Contrast tubing (DN)
TCAR essentials
- CTA (5 cm CCA, > 6 mm diameter), 0.625 mm cuts
- 3 days DAPT prior to procedure, or loading >4 hrs
- 5 days statin prior to procedure, or loading >12 hrs
- Balloon 3 cm length, 1:1 with healthy distal ICA
- Stent 1-2 oversized to CCA/carotid bulb
- Contraindication:
- acute thrombus in the ICA/CCA (life saver sign)
- long segment disease
- swollen ICA
- exophytic calcification
- >3mm circumferential calcification
Procedure
- start with on-table ultrasound
- femoral venous access, and place venous sheath, suture in place
- transverse neck incision between two heads of SCM, expose CCA, vessel loop, u-stitch pre-close, #access carotid artery, wire, microdilator 2-3 cm into CCA
- angiogram, exchange for stiff wire and stop wire short of the CCA, place en-route sheath, #assistant ties sheath in two places on the skin, potts the vessel
- connect the flow controller, toggle from low to high, fill the tubing while holding it up,
- press orange button to stop the flow, connect venous side angiogram
- 0.014 wire and balloon in place
- TCAR timeout
- occlude inflow with vessel loops wire cross lesion
- generous angioplasty
- deliver stent
- completion angiogram in 2 views release loops to re-establish antegrade flow
- disconnect arterial sheath and flow controller and give blood back via venous end remove sheath
- protamine
IFU
- 5 cm from the access to the lesion (previously clavicle to bifurcation)
- CCA > 6 mm
- ICA 4-9 mm
- TCAR is not safe without DAPT
- Contralateral occlusion is not a contraindication (10% of TCAR done with occlusion)
- About 80% are appropriate for TCAR
- SA/Plavix 3 days prior to procedure
- urgent, load ASA 650 and Plavix 300, 4 hours before procedure
- cagrelor 90 mg BID or 180 mg loading
