Use of distal embolic protection devices as a bailout strategy for suboptimal flow reversal during transcarotid artery revascularization: illustrative case.

BACKGROUND: Transcarotid artery revascularization (TCAR) has become an increasingly utilized surgical option for carotid disease, relying on flow reversal for distal embolic protection (DEP). However, anatomical variations, such as an isolated middle cerebral artery hemisphere, and severe carotid stenosis may compromise the safety of flow reversal intraoperatively. The authors describe the use of an adjunctive DEP device during TCAR as a "bailout" strategy for high-risk patients. OBSERVATIONS: The authors present the case of an adult patient with high-grade symptomatic carotid stenosis who was surgically managed with TCAR, requiring the adjunctive use of a DEP device due to insufficient flow reversal. The patient had a contralaterally occluded internal carotid artery, and poor retrograde flow was observed angiographically. The NAV6 Embolic Protection System was deployed through the transcarotid system. The case was successfully completed. There was no stroke perioperatively nor within 1 year postprocedure. LESSONS: For patients with poor flow reversal or isolated hemispheres during TCAR, adjunctive use of a DEP device may help mitigate the risks of distal embolization and periprocedural stroke. https://thejns.org/doi/10.3171/CASE25924.