Transcranial Doppler may increase the safety of thoracic endovascular aortic repair: A case report

Thoracic endovascular aortic repair (TEVAR) is a popular choice for treating aortic dissection and thoracic aneurysms. While TEVAR offers many benefits, it also creates a greater intraoperative embolic burden than open surgery due to direct endovascular contact with friable atherosclerotic lesions.Transcranial Doppler (TCD) is currently the only imaging modality that provides real-time feedback on the quantity and timing of intraprocedural microembolic signals (MES) while also continuously measuring cerebral blood flow velocity.We present the case of a 78-year-old male with prior supra-aortic trunk revascularization and a complex vascular anatomy who underwent repeat TEVAR for a type 1a endoleak. He was monitored with TCD to assess microembolization and ensure sufficient cerebral blood flow throughout the procedure. Intravascular ultrasound was also used to identify stenotic supraaortic graft segment.We found that TCD provided an additional layer of safety to the procedure by displaying real time cerebral flow velocities. The quantity and timing of microembolic signals during TEVAR offers feedback on current and new endovascular techniques with the aim of decreasing microembolic burden.