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Carotid-Carotid Transposition for Zone 1 Thoracic Endovascular Aortic Repair
Roberto G Aru1, Sam C Tyagi1, David J Minion1
1Division of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
Insights
Left-to-right carotid-carotid transposition (CCT) offers a safe, autologous option for maintaining left common carotid artery perfusion during zone I thoracic endovascular aortic repair (TEVAR). This study presents the initial experience with CCT as an alternative to carotid-carotid bypass.
Area of Science:
- Vascular Surgery
- Cardiovascular Surgery
- Aortic Surgery
Background:
- Carotid-carotid bypass is standard for cervical aortic arch debranching in zone I TEVAR.
- Left-to-right carotid-carotid transposition (CCT) is an autologous alternative.
- This study details the center's experience with CCT in zone I TEVAR.
Purpose of the Study:
- To evaluate the safety and efficacy of CCT for left common carotid artery revascularization.
- To compare CCT with carotid-carotid bypass in the context of zone I TEVAR.
- To report the outcomes of the first published series of CCT for this indication.
Main Methods:
- Retrospective review of 13 patients undergoing CCT (CPT code 35509) between 2017-2020.
- Analysis of patient demographics, indications, operative details, complications, and outcomes.
- Focus on CCT-specific complications and long-term patency.
Main Results:
- 13 patients underwent CCT prior to zone I TEVAR for aneurysms/dissections.
- High incidence of hypertension (92%), malnutrition (69%), and smoking (61%) noted.
- One transient recurrent laryngeal nerve deficit (7.7%); no cerebrovascular events or mortality.
- All transpositions remained patent without stenosis or thrombosis at average 7.2 months follow-up.
Conclusions:
- CCT is a safe and effective autologous alternative to carotid-carotid bypass.
- CCT provides reliable left common carotid artery revascularization for zone I TEVAR.
- No late complications related to CCT were observed in this cohort.
Objectives:
Carotid-carotid bypass is the standard technique for cervical aortic arch debranching to maintain left common carotid artery perfusion with zone I thoracic endovascular aortic repair (TEVAR), while left-to-right carotid-carotid transposition (CCT) has been described as an autologous alternative. We report on our center's experience with CCT in the setting of zone I TEVAR. This is the only published series of this technique.
Methods:
All patients who underwent CCT, defined by CPT code 35509, between 2017 and 2020 were identified at our tertiary care center. Patient demographics, indications for CCT, complications specific to CCT, operative details, post-operative course, and outcomes were retrospectively reviewed.
Results:
A total of 13 patients underwent CCT prior to zone 1 TEVAR. The indications for intervention were thoracic or thoracoabdominal aortic aneurysms and dissections secondary to hypertension (n = 10), Marfan syndrome (n = 2), and Turner syndrome with aneurysmal degeneration of previous coarctation repair (n = 1). There was a high incidence of preexisting hypertension (92%), malnutrition (69%), and smoking (61%) in this cohort. Operative intervention was performed on both an elective (n = 7, 54%) and an urgent (n = 6, 46%) basis. Complications directly related to CCT included transient unilateral recurrent laryngeal nerve deficit (n = 1, 7.7%). There were no cerebrovascular events, surgical site infections, or procedure-related mortalities. All transpositions with follow-up imaging were patent without stenosis or thrombosis (average 7.2 months, n = 10). There were no late complications related to CCT.
Conclusions:
CCT is a safe and autologous alternative to carotid-carotid bypass for left common carotid artery revascularization with zone I TEVAR.
