PURPOSE: The purpose of this study was to evaluate the effect of a thoracic hyperextension (THE) positioning maneuver on clavicle-to-carotid bifurcation (CCB) distance in patients undergoing transcarotid artery revascularization (TCAR) and to determine whether this technique may expand anatomic eligibility for TCAR for patients with CCB <5 cm. MATERIALS AND METHODS: Consecutive patients who underwent TCAR between August 2022 and November 2023 by a single surgeon were included. All patients were positioned using the THE maneuver. Preoperative straight-line computed tomography angiography (CTA) was used to measure CCB distance. Immediately preincision, CCB distance was remeasured using ultrasound after THE positioning. The primary outcome was change in CCB distance; a ≥0.5 cm increase was considered meaningful. Secondary outcomes included 30-day death, stroke, myocardial infarction (MI), and cranial nerve injury. RESULTS: A total of 44 patients underwent TCAR (mean age: 74.6 years; 89% male). Technical success was 100%. The median preoperative CCB distance by CTA was 6.7 cm (interquartile range IQR: 6.0–7.6 cm). After THE positioning, the median US-measured distance increased to 8.0 cm (IQR: 7.2–9.0 cm) ( P < 0.001). The median absolute gain was 1.2 cm (IQR: 0.8–1.7 cm; relative gain: 16.3%), with 88.6% achieving ≥0.5 cm increase. Five patients with borderline or subthreshold CTA measurements achieved postpositioning distances meeting TCAR anatomic criteria. No 30-day death, stroke, MI, or cranial nerve injury occurred. CONCLUSION: THE maneuver is a simple positioning technique that appears to increase CCB distance and may have the potential to expand TCAR eligibility without additional cost. Its use may be particularly relevant in patients with low or borderline carotid bifurcations; however, further prospective studies are needed to confirm its clinical impact and reproducibility.
Chen et al. (Thu,) studied this question.