TCAR: Difference between revisions

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TCAR essentials
==TCAR essentials==
CTA (5 cm CCA, > 6 mm diameter), 0.625 mm cuts 3 days DAPT prior to procedure, or loading >4 hrs
*CTA (5 cm CCA, > 6 mm diameter), 0.625 mm cuts  
5 days statin prior to procedure, or loading >12 hrs Balloon 3 cm length, 1:1 with healthy distal ICA
*3 days DAPT prior to procedure, or loading >4 hrs
Stent 1-2 oversized to CCA/carotid bulb
*5 days statin prior to procedure, or loading >12 hrs  
Contraindication: acute thrombus in the ICA/CCA (life saver sign), long segment disease, swollen ICA, exophytic calcification, >3mm circumferential calcification
*Balloon 3 cm length, 1:1 with healthy distal ICA
start with on-table ultrasound
*Stent 1-2 oversized to CCA/carotid bulb
femoral venous access, and place venous sheath, suture in place
*Contraindication:  
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
**acute thrombus in the ICA/CCA (life saver sign)  
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
**long segment disease
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
**swollen ICA
0.014 wire and balloon in place
**exophytic calcification
TCAR timeout
**>3mm circumferential calcification
occlude inflow with vessel loops wire cross lesion
 
generous angioplasty deliver stent
#start with on-table ultrasound
completion angiogram in 2 views release loops to re-establish antegrade flow
#femoral venous access, and place venous sheath, suture in place
disonnect arterial sheath and flow controller and give blood back via venous end remove sheath
#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
protamine
#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
IFU
#connect the flow controller, toggle from low to high, fill the tubing while holding it up,  
5 cm from the access to the lesion (previously clavicle to bifurcation)
#press orange button to stop the flow, connect venous side angiogram
CCA > 6 mm
#0.014 wire and balloon in place
ICA 4-9 mm
#TCAR timeout
TCAR is not safe without DAPT
#occlude inflow with vessel loops wire cross lesion
Contralateral occlusion is not a contraindication (10% of TCAR done with occlusion)
#generous angioplasty  
About 80% are appropriate for TCAR
#deliver stent
SA/Plavix 3 days prior to procedure
#completion angiogram in 2 views release loops to re-establish antegrade flow
urgent, load ASA 650 and Plavix 300, 4 hours before procedure cagrelor 90 mg BID or 180 mg loading
#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

Revision as of 20:42, 6 November 2024

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
  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
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