Hybrid revascularization for acute common carotid artery occlusion after transcarotid transcatheter aortic valve implantation: illustrative case.

BACKGROUND: Transcarotid transcatheter aortic valve implantation (TC-TAVI) is an alternative access route for patients in whom transfemoral TAVI is not suitable. Although carotid complications are uncommon, they may occur because of direct carotid manipulation. We report a rare case of acute common carotid artery occlusion after TC-TAVI treated with hybrid revascularization. OBSERVATIONS: A 94-year-old woman underwent TC-TAVI through the left common carotid artery because severe iliofemoral calcification precluded transfemoral access. After the procedure, delayed emergence from general anesthesia, aphasia, and right hemiparesis developed. MRI demonstrated scattered infarctions in the left middle cerebral artery territory, and CT angiography revealed left common carotid artery occlusion. The mechanism and extent of the lesion could not be adequately determined preoperatively. Potential etiologies included repair site stenosis, thrombotic occlusion, and carotid dissection. Therefore, hybrid surgery was selected. Direct inspection revealed localized posterior wall intimal injury associated with subintimal hematoma and thrombus formation. Thrombectomy and intimal resection achieved complete recanalization with neurological improvement. LESSONS: Acute common carotid artery occlusion is a rare but potentially devastating complication of TC-TAVI. Careful patient selection for transcarotid access is essential. When the mechanism and extent of carotid occlusion cannot be adequately defined preoperatively, hybrid surgery may provide definitive diagnosis and safe revascularization. https://thejns.org/doi/10.3171/CASE26527.