Presentations

Abstract

Introduction: Transcarotid artery revascularization (TCAR) is a carotid stenting technique that offers a smaller incision than carotid endarterectomy (CEA), cerebrovascular protection through arterial flow reversal, and does not require crossing the aortic arch. Since approval, TCAR has demonstrated comparable postoperative stroke and complication rates to CEA. One rarely described TCAR complication is the occurrence of pneumothorax, as described in the case below.

Case Information: Case report of a 56-year-old female with a history of tobacco use, hyperlipidemia, rheumatoid arthritis, gastroesophageal reflux disease, and macular degeneration presenting with acute right eye vision loss and headache. Duplex study revealed total occlusion of the right internal carotid artery (ICA) and a critical 80-99% occlusion of the left ICA. Left TCAR was performed with postoperative chest radiograph (CXR) revealing large left-sided and moderate right-sided pneumothoraces. Bilateral percutaneous chest tubes were placed and the patient proceeded with recovery, which was uncomplicated. On Post Operative Day 3 (POD 3), both chest tubes were removed, followed by a CXR demonstrating no residual pneumothoraces. The patient was discharged that day. At one-month follow-up, the patient exhibited no further shortness of breath nor chest pain, and a repeat duplex study revealed a patent left internal carotid artery stent with no evidence of restenosis.

Discussion/Clinical Findings: We present, to our knowledge, the first case of bilateral pneumothoraces post-TCAR. Pneumothoraces resulting from TCAR may be avoided by identifying and screening high risk individuals preoperatively. Patients diagnosed with chronic obstructive pulmonary disease (COPD) and emphysema may require a close review of preoperative imaging to establish the proximity of the pleural apex to the common carotid artery (CCA). Careful and gentle dissection at the region of the root of the neck with preservation of the Sibson fascia is important to prevent this complication during TCAR. In cases where there is clear entry to the pleural space and a significant clinical concern for pneumothorax, a small-tube thoracostomy may be performed postoperatively to decompress the pleural space.

Conclusion: As a result of dissection into the base of the neck during TCAR, the Sibson fascia covering the apex of the lung may be compromised. Pneumothorax following low dissection is a common occurrence that has been described during thoracic outlet syndrome operations using a supraclavicular incision. A unilateral pneumothorax can potentially lead to pneumomediastinum or bilateral pneumothoraces if air from the ruptured lung leaks into the mediastinum, which can then spread into the contralateral pleural space. This can occur through anatomical pathways such as the pulmonary hila or the fascial planes surrounding the trachea and esophagus and can be treated with chest-tube placement.