Background
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are accepted revascularization
modalities to treat carotid artery stenosis. Higher incidences of perioperative adverse
neurological events and death have been reported in patients with transfemoral CAS.
Transcarotid artery revascularization (TCAR) is a newer operative technique that involves
direct transcervical carotid access, mitigating aortic arch manipulation and minimizing
the risk of embolic stroke via cerebral blood flow reversal. Perioperative stroke,
myocardial infarction (MI), and death rates have been shown to be similar between
TCAR and CEA, with TCAR having fewer complications. The objective of this study was
to ascertain the safety and viability of TCAR by evaluating perioperative outcomes.
We hypothesized that patients undergoing TCAR and CEA have equivalent outcomes.
Methods
We performed a single-institution retrospective review of a prospectively maintained
Vascular Quality Initiative database on patients who underwent TCAR or CEA between
2012 and 2019. A total of 66 TCAR cases from February 2018 to December 2019 and 501
CEA cases from January 2012 to December 2019 were reviewed. Preoperative, intraoperative,
and postoperative characteristics as well as perioperative outcomes were captured
for the statistical analyses.
Results
From 2012 to 2019, 567 patients underwent TCAR or CEA. Patients who underwent TCAR
were found to have higher rates of comorbidities compared with CEA. There were no
procedure-related strokes in patients who underwent TCAR. There was no statistically
significant difference between TCAR and CEA procedure-related strokes (0% vs. 1.0%,
P = 0.42). There were 5 CEA procedure-related strokes because of technical problems
resulting in thrombosis of the target vessels. Three patients who underwent CEA had
strokes unrelated to the operations. Overall, there were no perioperative deaths,
MI, cranial nerve injury (CNI), or hematoma in patients who underwent TCAR. There
were no complications of surgical site infection, pseudoaneurysm, or arteriovenous
fistula among patients who underwent TCAR or CEA.
Conclusions
This single-center retrospective analysis of TCAR and CEA for the treatment of carotid
artery disease suggests TCAR can result in equivalent perioperative procedure-related
stroke as CEA as well as equivalent incidence of perioperative complications including
MI, CNI, hematoma, and death in selected patients or patients with proper anatomy.
TCAR may be considered a safe, feasible carotid revascularization option for carotid
artery stenosis.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Annals of Vascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Ischemic stroke subtypes: a population-based study of incidence and risk factors.Stroke. 1999; 30: 2513-2516
- Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study.Stroke. 2001; 32: 2735-2740
- Percutaneous transluminal angioplasty and stenting for carotid artery stenosis.Cochrane Database Syst Rev. 2007; 4: CD000515
- Stenting versus endarterectomy for treatment of carotid-artery stenosis.N Engl J Med. 2010; 363: 11-23
- Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery.J Vasc Surg. 2008; 48: 480-486
- Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary.J Vasc Surg. 2011; 54: 832-836
- Preprocedural risk stratification: identifying an appropriate population for carotid stenting.J Vasc Surg. 2001; 33: 728-732
- Long-term results of carotid stenting versus endarterectomy in high-risk patients.N Engl J Med. 2008; 358: 1572-1579
- Protected carotid-artery stenting versus endarterectomy in high-risk patients.N Engl J Med. 2004; 351: 1493-1501
- Long-term follow-up study of endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis trial.Stroke. 2014; 45: 2750-2756
- Long-term results of stenting versus endarterectomy for carotid-artery stenosis.N Engl J Med. 2016; 374: 1021-1031
- A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs stenting.J Vasc Surg. 2011; 53: 792-797
- Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial.Lancet. 2010; 375: 985-997
- Mechanisms to explain the poor results of carotid artery stenting (CAS) in symptomatic patients to date and options to improve CAS outcomes.J Vasc Surg. 2010; 52: 1367-1375
- The CAPTURE registry: analysis of strokes resulting from carotid artery stenting in the post approval setting: timing, location, severity, and type.Ann Surg. 2007; 246: 551-558
- Transcervical carotid stenting with internal carotid artery flow reversal: feasibility and preliminary results.J Vasc Surg. 2004; 40: 476-483
- Transcarotid artery revascularization as a new modality of treatment for carotid stenosis.Ann Vasc Surg. 2020; 64: 397-404
- Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal.J Vasc Surg. 2015; 62: 1227-1234
- Transcarotid artery revascularization with flow reversal.J Endovasc Ther. 2017; 24: 265-270
- Outcomes associated with a transcarotid artery revascularization-centered protocol in high-risk carotid revascularizations using the ENROUTE neuroprotection system.J Vasc Surg. 2019; 69: 807-813
- Association of transcarotid artery revascularization vs transfemoral carotid artery stenting with stroke or death among patients with carotid artery stenosis.JAMA. 2019; 322: 2313-2322
- Complexity of aortic arch anatomy affects the outcomes of transcarotid artery revascularization versus transfemoral carotid artery stenting.Ann Vasc Surg. 2020; 67: 78-89
- A multi-institutional analysis of transcarotid artery revascularization compared to carotid endarterectomy.J Vasc Surg. 2019; 70: 123-129
- Propensity-matched outcomes of transcarotid artery revascularization versus carotid endarterectomy.J Surg Res. 2020; 252: 22-29
- Stenting and angioplasty with protection in patients at high-risk for endarterectomy: SAPPHIRE Worldwide Registry first 2,001 patients.Catheter Cardiovasc Interv. 2009; 73: 129-136
- Protected carotid stenting in high-surgical-risk patients: the ARCHeR results.J Vasc Surg. 2006; 44: 258-268
- 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomized non-inferiority trial.Lancet. 2006; 368: 1239-1247
- Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial.Lancet Neurol. 2008; 7: 893-902
- Perioperative and one-year TransCarotid revascularization outcomes in symptomatic patients.J Vasc Surg. 2020; 72: 2047-2053
Article Info
Publication History
Published online: November 25, 2020
Accepted:
October 14,
2020
Received:
July 18,
2020
Footnotes
Declarations of interest: none.
Competing interest statement: All authors have no competing interests to declare.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
