Advertisement

Institutional Experiences with Transfemoral Compared to Transcarotid Stenting

  • Alejandro Olvera
    Affiliations
    Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
    Search for articles by this author
  • Katherin Leckie
    Affiliations
    Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
    Search for articles by this author
  • Akiko Tanaka
    Affiliations
    Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
    Search for articles by this author
  • Raghu L. Motaganahalli
    Affiliations
    Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
    Search for articles by this author
  • Mackenzie K. Madison
    Affiliations
    Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
    Search for articles by this author
  • Arash Keyhani
    Affiliations
    Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
    Search for articles by this author
  • Kourosh Keyhani
    Affiliations
    Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
    Search for articles by this author
  • S. Keisin Wang
    Correspondence
    Correspondence to: S. Keisin Wang MD, RPVI, Assistant Professor of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, 1631 North Loop West, Suite 610, Houston, TX 77008, USA
    Affiliations
    Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
    Search for articles by this author
Published:April 22, 2022DOI:https://doi.org/10.1016/j.avsg.2022.04.020

      Background

      Transcarotid artery revascularization (TCAR) is a new surgical technique that is gaining popularity over the transfemoral method (TF-CAS) as the preferred strategy to deliver a carotid stent. This investigation was performed to evaluate the real-world perioperative and long-term outcomes of both techniques at the health system level.

      Methods

      A retrospective review of prospectively maintained carotid revascularization databases were performed at 2 high-volume TCAR centers in the United States to extract consecutive TF-CAS and TCAR procedures. The characteristics and outcomes associated with these 2 modalities were compared at the preoperative and perioperative points by univariate methods. The Kaplan–Meier methodology was utilized to calculate the long-term stroke and death trends.

      Results

      From 2008–2021, 1,058 carotid stents were implanted at our institutions, consisting of 750 TCARs and 308 TF-CAS procedures. Patients undergoing TF-CAS were older (68.2 ± 0.6 vs. 73.1 ± 0.3 years, P < 0.01) and unhealthier by Charlson Comorbidity Index (4.9 ± 0.1 vs. 5.5 ± 0.1, P < 0.01). Additionally, TF-CAS patients had more high-risk anatomic characteristics, such as restenosis after previous carotid surgery (27.0% vs. 9.5%, P < 0.01), previous ipsilateral neck surgery (38.8% vs. 11.5%, P < 0.01), irradiated ipsilateral field (20.4% vs. 4.5%, P < 0.01), and a contralateral carotid occlusion (10.4% vs. 4.6%, P < 0.01). The incidence of symptomatic lesions was the same (40.1% vs. 36.9%, P = 0.35). Within the operating room, TCAR outperformed TF-CAS with respect to operative time (83.2 ± 2.6 vs. 64.3 ± 0.9 min, P < 0.01), radiation exposure (769.9 ± 144.3 vs. 232.7 ± 19.1 mGys, P < 0.01), fluoroscopic time (17.8 ± 1.1 vs. 4.5 ± 0.1 min, P < 0.01), and contrast volume (75.2 ± 2.4 vs. 22.6 ± 0.4 mLs, P < 0.01).
      In the 30-day perioperative period, ipsilateral stroke (2.8% vs. 2.3%, P = 0.65), contralateral stroke (1.0% vs. 0.1%, P = 0.07), and death (1.0% vs. 1.2%, P > 0.99) were similar between modalities. None of these endpoints, including a composite of stroke and death (4.8% vs. 3.6%, P = 0.38), reached statistical significance. Additionally, we found no differences with respect to stroke-free survival between modalities during follow-up by Kaplan–Meier analysis (P = 0.30).

      Conclusions

      In this combined experience from 2 large health systems, TCAR was associated with less intraoperative complexity, as measured by operative time, radiation exposure, and contrast volume. Although stroke and death seemed to be less frequent in patients undergoing transcervical stenting, this did not reach statistical significance.
      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 access
      One-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 Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Criado E.
        • Doblas M.
        • Fontcuberta J.
        • et al.
        Transcervical carotid stenting with internal carotid artery flow reversal: feasibility and preliminary results.
        J Vasc Surg. 2004; 40: 476-483
        • Parodi J.C.
        • Schönholz C.
        • Ferreira L.M.
        • et al.
        “Seat belt and air bag” technique for cerebral protection during carotid stenting.
        J Endovasc Ther. 2002; 9: 20-24
        • Kwolek C.J.
        • Jaff M.R.
        • Leal J.I.
        • et al.
        Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal.
        J Vasc Surg. 2015; 62: 1227-1234
        • Cronenwett J.L.
        • Kraiss L.W.
        • Cambria R.P.
        The society for vascular surgery vascular quality initiative.
        J Vasc Surg. 2012; 55: 1529-1537
        • Schermerhorn M.L.
        • Liang P.
        • Eldrup-Jorgensen J.
        • et al.
        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
        • Malas M.B.
        • Dakour-Aridi H.
        • Kashyap V.S.
        • et al.
        Transcarotid revascularization with dynamic flow reversal versus carotid endarterectomy in the vascular quality initiative surveillance project.
        Ann Surg. 2020; (Epub ahead of print)https://doi.org/10.1097/SLA.0000000000004496
        • Johnston L.E.
        • Robinson W.P.
        • Tracci M.C.
        • et al.
        Vascular Quality Initiative and National Surgical Quality Improvement Program registries capture different populations and outcomes in open infrainguinal bypass.
        J Vasc Surg. 2016; 64: 629-637
        • Cappellini C.A.
        • Zheng H.
        • Lamb K.M.
        • et al.
        Outcomes of transcarotid artery revascularization and carotid endarterectomy at a single institution.
        Ann Vasc Surg. 2021; 73: 329-335
        • Zebolsky A.L.
        • Chou J.
        • Key P.
        • et al.
        Safety and efficacy of transcarotid artery revascularization in a community hospital.
        J Vasc Surg. 2021; 74: 203-208
        • Wang S.K.
        • Fajardo A.
        • Sawchuk A.P.
        • et al.
        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
        • AbuRahma A.F.
        • Avgerinos E.D.
        • Chang R.W.
        • et al.
        Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease.
        J Vasc Surg. 2022; 75: 4S-22S
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • et al.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • King A.H.
        • Kumins N.H.
        • Foteh M.I.
        • et al.
        The learning curve of transcarotid artery revascularization.
        J Vasc Surg. 2019; 70: 516-521
        • Brott T.G.
        • Hobson 2nd, R.W.
        • Howard G.
        • et al.
        Stenting versus endarterectomy for treatment of carotid-artery stenosis.
        N Engl J Med. 2010; 363: 11-23
        • Brott T.G.
        • Howard G.
        • Roubin G.S.
        • et al.
        Long-term results of stenting versus endarterectomy for carotid-artery stenosis.
        N Engl J Med. 2016; 374: 1021-1031
        • Ringleb P.A.
        • Allenberg J.
        • Brückmann H.
        • et al.
        30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial.
        Lancet Lond Engl. 2006; 368: 1239-1247
        • Yadav J.S.
        • Wholey M.H.
        • Kuntz R.E.
        • et al.
        Protected carotid-artery stenting versus endarterectomy in high-risk patients.
        N Engl J Med. 2004; 351: 1493-1501
        • Hicks C.W.
        • Nejim B.
        • Locham S.
        • et al.
        Association between Medicare high-risk criteria and outcomes after carotid revascularization procedures.
        J Vasc Surg. 2018; 67: 1752-1761.e2
        • Malas M.B.
        • Elsayed N.
        • Naazie I.
        • et al.
        Propensity score-matched analysis of 1-year outcomes of transcarotid revascularization with dynamic flow reversal, carotid endarterectomy, and transfemoral carotid artery stenting.
        J Vasc Surg. 2022; 75: 213-222.e1
        • Mehta A.
        • Patel P.B.
        • Bajakian D.
        • et al.
        Transcarotid artery revascularization versus carotid endarterectomy and transfemoral stenting in octogenarians.
        J Vasc Surg. 2021; 74: 1602-1608
        • Naazie I.N.
        • Cui C.L.
        • Osaghae I.
        • et al.
        A systematic review and meta-analysis of transcarotid artery revascularization with dynamic flow reversal versus transfemoral carotid artery stenting and carotid endarterectomy.
        Ann Vasc Surg. 2020; 69: 426-436
        • Chang H.
        • Rockman C.B.
        • Veith F.J.
        • et al.
        Outcomes of transfemoral carotid artery stenting and transcarotid artery revascularization for restenosis after prior ipsilateral carotid endarterectomy.
        J Vasc Surg. 2022; 75: 561-571.e3