Transcarotid Artery Revascularization: How to Overcome Anatomical Boundaries With Prosthetic Conduit

Carotid artery stenosis boasts a wide variety of techniques available for intervention when indicated. Of these, the transcarotid artery revascularization (TCAR) demonstrates benefit in high-risk patients with outcomes and complications comparable to carotid endarterectomy (CEA). Often times, anatomic constraints such as common carotid artery (CCA) length or presence of thrombus may preclude TCAR. This study describes a modification to TCAR using a prosthetic conduit to extend the CCA runway. Three patients with such prohibitive anatomy underwent TCAR with a prosthetic conduit. This was performed using a 6 mm Dacron limb anastomosed to the CCA. The sheath for the TCAR was then introduced into the prosthetic, allowing a safe runway with appropriate length for minimal manipulation of the CCA. Each patient then underwent the remainder of the TCAR in standard fashion, with ligation of conduit and oversewing the cuff at case conclusion. Overall operative and flow reversal time were comparable to conventional TCAR, with no complications noted. Transcarotid artery revascularization with a conduit is a useful modification in patients with anatomic limitations to standard TCAR and expands the inclusion criteria of patients considered for TCAR with no apparent additional risk or significant differences in operative or flow reversal time.Clinical ImpactThis study demonstrates that the use of a prosthetic conduit is a safe and practical modification of transcarotid artery revascularization (TCAR) in patients with an inadequate common carotid artery runway or unfavorable anatomy. By extending the applicability of TCAR beyond standard anatomic criteria, this technique allows clinicians to avoid higher-risk alternatives such as redo carotid endarterectomy or transfemoral carotid stenting in select patients. The innovation lies in minimizing manipulation of the native carotid artery while preserving standard TCAR flow-reversal neuroprotection. Incorporation of this approach expands the vascular surgeon's technical armamentarium and may broaden access to TCAR without compromising procedural safety or efficiency.