TCAR

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

• I-Stat & ACT cartridges (Perfusionist room or borrow from IR)

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 Supplies:

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 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 disonnect 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