TCAR

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

1. start with on-table ultrasound
2. femoral venous access, and place venous sheath, suture in place
3. 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
4. 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
5. connect the flow controller, toggle from low to high, fill the tubing while holding it up,
6. press orange button to stop the flow, connect venous side angiogram
7. 0.014 wire and balloon in place
8. TCAR timeout
9. occlude inflow with vessel loops wire cross lesion
10. generous angioplasty
11. deliver stent
12. completion angiogram in 2 views release loops to re-establish antegrade flow
13. disconnect arterial sheath and flow controller and give blood back via venous end remove sheath
14. 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