Hybrid revascularization for acute common carotid artery occlusion after transcarotid transcatheter aortic valve implantation: illustrative case

Figures

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  FIG. 1.. Preoperative CT angiogram demonstrating extensive calcification and stenosis involving the distal abdominal aorta and bilateral iliofemoral arteries, rendering transfemoral access unsuitable for TAVI.

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  FIG. 2.. Postprocedural images. A and B: Diffusion-weighted MR images demonstrating multiple scattered infarctions predominantly in the left middle cerebral artery territory. C: MR angiogram showing poor visualization of the left internal carotid artery and middle cerebral artery. D: Three-dimensional CT angiogram demonstrating complete occlusion of the left common carotid artery.

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  FIG. 3.. Hybrid endovascular procedure and angiographic outcome. A: Initial angiogram demonstrating near-complete occlusion of the left common carotid artery. B: Direct visualization and grasping of a transfemorally introduced guidewire within the operative field. C: Advancement of an 8-Fr balloon guide catheter to the common carotid artery origin for proximal flow control. D: Final angiographic assessment. Cervical angiograms demonstrating restoration of antegrade common carotid artery flow (left) and complete recanalization of the intracranial circulation (right).

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  FIG. 4.. Intraoperative findings during hybrid revascularization. A: Reexposure of the carotid repair site after removal of the stenotic suture line. B: Thickened intima and localized posterior wall intimal injury. C: Subintimal hematoma associated with the injured intima. D: Organized thrombus associated with the intimal injury was removed under proximal flow control with saline flushing through the balloon guide catheter. E: Operative field before carotid resuturing after thrombectomy and intimal resection.

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  FIG. 5.. Proposed mechanism of carotid artery occlusion after TC-TAVI. Schematic illustration showing localized posterior wall intimal injury adjacent to the carotid repair site, resulting in subintimal hematoma formation, progressive thrombus propagation, and subsequent common carotid artery occlusion. ECA = external carotid artery; ICA = internal carotid artery.