Transcarotid artery revascularization versus transfemoral carotid artery stenting in the Society for Vascular Surgery Vascular Quality Initiative

Transcarotid Artery Revascularization for Symptomatic Retropharyngeal Internal Carotid Artery Stenosis

Retropharyngeal internal carotid artery (ICA) is a rare, yet well-described anatomical variant that poses significant challenges to the management of carotid artery stenosis. In this case report, we discuss the treatment of symptomatic ICA stenosis with a retropharyngeal ICA using the transcarotid artery revascularization (TCAR) technique. A 70-year-old female with comorbidities presented with neurological symptoms and severe ICA stenosis. After diagnostic evaluation, TCAR was chosen for surgical intervention. The patient did well postoperatively. This case emphasizes the importance of considering TCAR when treating ICA stenosis in patients with anatomic variation of ICA location. It also supports adding anatomic variants such as retropharyngeal ICA to the list of indications for TCAR.

An International, Expert-Based Delphi Consensus Document on Controversial Issues about TransCarotid Artery Revascularization (TCAR)

OBJECTIVE

TransCarotid Artery Revascularization (TCAR) has emerged as an alternative therapeutic modality to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) for the management of patients with carotid artery stenosis. However, certain issues regarding the indications and contraindications of TCAR remain unanswered or unresolved. The aim of this international, expert-based Delphi Consensus document was to attempt to provide some guidance on these topics.

METHODS

A 3-Round Delphi Consensus process was performed including 29 experts. The aim of Round 1 was to investigate the differing views and opinions of the participants. Round 2 was carried out after the results from the literature on each topic were provided to the participants. During Round 3, the participants had the opportunity to finalize their vote.

RESULTS

Most participants agreed that TCAR can/can probably/possibly be performed within 14 days of a cerebrovascular event, but it is best to avoid it in the first 48 hours. It was felt that TCAR cannot/should not replace TFCAS or CEA, as each procedure has specific indications and contraindications. Symptomatic patients >80 years should probably be treated with TCAR rather than with TFCAS. TCAR can/can probably be used for the treatment of restenosis following CEA/TFCAS. Finally, there is a need for a randomized controlled trial to provide better evidence for the unresolved issues.

CONCLUSIONS

This Delphi Consensus document attempted to assist the decision-making of physicians/interventionalists/vascular surgeons involved in the management of carotid stenosis patients. Furthermore, areas requiring additional research were identified. Future studies and randomized controlled trials should provide more evidence to address the unanswered questions regarding TCAR.

Endovascular stenting techniques for blunt carotid injury

OBJECTIVES

While methods of endovascular carotid artery stenting have improved over time, concerns surrounding the safety and efficacy of stenting for blunt carotid injury (BCI) remain. This study aims to present our approach to carotid artery stenting (CAS) by incorporating new technologies such as flow-diverting stents and circuits.

METHODS

There is no robust evidence to support routine carotid artery stenting; however, there are several therapeutic options and approaches for treating BCI that currently require an individualized approach. Endovascular stenting and specific stent selection are largely dictated by the disease process the surgeon intends to treat. We will discuss patient selection, medical management, and the most common revascularization techniques, including transfemoral stenting, trans-carotid arterial revascularization using flow reversal, and stent-assisting coiling.

RESULTS

It must be stressed that endovascular intervention is not an alternative to or preclusive of antithrombotic or anticoagulant therapy. In the setting of BCI, transfemoral CAS is most appropriate in patients who are symptomatic, have a rapidly progressing or large lesion, and do not have a soft thrombus present due to risk of embolism. Unlike transfemoral CAS, TCAR offers an elegant solution for embolic protection when patients have a soft thrombus present. In the case of a large pseudoaneurysm, we perform stent-assisted coiling.

CONCLUSIONS

We practice selective endovascular intervention, stenting lesions that are flow-limiting or have large or rapidly expanding pseudoaneurysms, and only in patients for whom anticoagulation and antiplatelet agents are not contraindicated. As technology and investigation progress, the concerns regarding the safety and the role of endovascular intervention in the treatment of BCI will be more clearly defined.

What Is the Best Technique for Treating Carotid Disease?

This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient's medical comorbidities and anatomic factors.

Emergency medicine updates: Transient ischemic attack

INTRODUCTION

Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning TIA for the emergency clinician.

DISCUSSION

TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic.

CONCLUSIONS

An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.

Multi-center experience with intravascular lithotripsy for treatment of severe calcification during transcarotid artery revascularization for high-risk patients

OBJECTIVE

Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication in carotid artery stenting. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease.

METHODS

All consecutive patients who underwent TCAR+IVL from 2018-2022 at nine institutions were identified. IVL was combined with pre-dilatation angioplasty to treat calcified vessels before stent deployment. The primary outcome was a new ipsilateral stroke within 30 days. Secondary outcomes included any new ipsilateral neurologic event (stroke/transient ischemic attack [TIA]) at 30 days, technical success, and <30% residual stenosis.

RESULTS

Fifty-eight patients (62% male; mean age, 78 ± 6.6 years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87 ± 27 minutes and 25 ± 14 minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29 mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having <30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30 days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P = .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P = .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132 days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period.

CONCLUSIONS

IVL sufficiently remodels calcified carotid arteries to facilitate TCAR effectively in patients with traditionally prohibitive calcific disease. One patient (1.7%) suffered a stroke within 30 days, although four patients (6.8%) sustained any new neurological event (stroke/TIA). These results raise concerns about the risks of TCAR+IVL and whether it is an appropriate strategy for patients who could potentially undergo CEA.

The effect of controlled vs uncontrolled hypertension on outcomes of carotid revascularization procedures

BACKGROUND

Hypertension (HTN) has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled HTN (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population.

METHODS

We studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from the Vascular Quality Initiative. Patients were stratified into two groups: those with cHTN and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure of <130/80 mm Hg. Patients with uHTN had a blood pressure of ≥130/80 mm Hg. Our primary outcomes were in-hospital stroke, death, myocardial infarction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension or HTN, reperfusion syndrome, prolonged length of stay (LOS) (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis.

RESULTS

A total of 34,653 CEA (uHTN, 11,347 [32.7%]), 8199 TFCAS (uHTN, 2307 [28.1%]), and 17,309 TCAR (uHTN, 4990 [28.8%]) patients were included in this study. There was no significant difference in age between patients with cHTN and patients with uHTN for each carotid revascularization procedure. However, compared with patients with cHTN, patients with uHTN had significantly more comorbidities. uHTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR], 1.56; 95% confidence interval [CI], 1.30-1.87; P < .001), TFCAS (aOR, 1.59; 95% CI, 1.21-2.08; P < .001), and TCAR (aOR, 1.39; 95% CI, 1.12-1.73; P = .003) compared with cHTN. Additionally, uHTN was associated with a prolonged LOS after all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR, 1.82; 95% CI, 1.39-2.37; P < .001), in-hospital death (aOR, 3.73; 95% CI, 2.25-6.19; P < .001), reperfusion syndrome (aOR, 6.24; 95% CI, 3.57-10.93; P < .001), and extended LOS (aOR, 1.87; 95% CI, 1.51-2.32; P < .001) compared with CEA. There was no statistically significant difference between the outcomes of TCAR compared with CEA.

CONCLUSIONS

The results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with cHTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. Additionally, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be safer interventions. Patients with uTHN with symptomatic carotid disease treated with CEA or TCAR have better outcomes compared with those treated with TFCAS.

Postoperative outcomes in patients with anemia undergoing carotid revascularization

BACKGROUND

Preoperative anemia is associated with worse postoperative morbidity and mortality after major vascular procedures. Limited research has examined the optimal method of carotid revascularization in patients with anemia. Therefore, we aim to compare the postoperative outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among patients with anemia.

STUDY DESIGN

This is a retrospective review of patients with anemia undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016 and 2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACEs). Logistic regression models were used for multivariate analyses.

RESULTS

Our study included 40,383 CEA (59.3%), 9159 TFCAS (13.5%), and 18,555 TCAR (27.3%) cases in patients with anemia. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with decreased 30-day mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.37-0.59; P < .001), in-hospital MACE (aOR, 0.58; 95% CI, 0.46-0.75; P < .001) compared with TFCAS. Additionally, TCAR was associated with a 20% decrease in the risk of 30-day mortality (aOR, 0.80; 95% CI, 0.65-0.98; P = .03) and a similar risk of in-hospital MACE (aOR, 0.86; 95% CI, 0.77-1.01; P = .07) compared with CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR, 2; 95% CI, 1.5-2.68; P < .001) and in-hospital MACE (aOR, 1.7; 95% CI, 1.4-2; P < .001) compared with CEA.

CONCLUSIONS

In this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS is associated with a high risk of 30-day mortality and in-hospital MACE compared with CEA and TCAR in patients with anemia. TCAR was associated with a lower risk of 30-day mortality compared with CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in patients with anemia.

Transcarotid artery revascularization outperforms transfemoral carotid artery stenting regardless of aortic arch type or degree of atherosclerosis

OBJECTIVE

The Centers for Medicare and Medicaid Services now approve reimbursement for transfemoral carotid artery stenting (TFCAS) in the treatment of standard-risk patients with carotid artery occlusive disease. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes. Transcarotid artery revascularization (TCAR) could be a preferable alternative in these patients owing to avoiding the aortic arch and using flow reversal during stent deployment. We aim to compare the outcomes of TCAR vs TFCAS across all aortic arch types and degrees of arch atherosclerosis.

METHODS

All patients undergoing carotid artery stenting between September 2016 and October 2023 were identified in the Vascular Quality Initiative database. Patients were stratified into four groups: Group A (mild atherosclerosis and type I/II arch), Group B (mild atherosclerosis and type III arch), Group C (moderate/severe atherosclerosis and type I/II arch), and Group D (moderate/severe atherosclerosis and type III arch). The primary outcome was in-hospital composite stroke or death. Analysis of variance and χ2 tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. Kaplan-Meier survival estimates, log rank test, and multivariable Cox regression models analyzed hazard ratios for 1-year mortality.

RESULTS

A total of 20,114 patients were included (Group A: 12,980 [64.53%]; Group B: 1175 [5.84%]; Group C: 5124 [25.47%]; and Group D: 835 [4.15%]). TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94%, and 69.22%; P < .001). Compared with patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group C and Group D were more likely to be female, hypertensive, smokers, and have chronic kidney disease. Patients with type III arch in Group B and Group D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than one-half the risk of stroke/death and 1-year mortality compared with TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (Group A) (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .001; hazard ratio, 0.42; 95% CI, 0.32-0.57; P < .001). Group B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared with TFCAS (OR, 0.30; 95% CI, 0.12-0.75; P = .01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR, 0.66; 95% CI, 0.44-0.97; P = .037). There was no significant difference in odds of stroke/death in patients with advanced arch atherosclerosis and complex arch (Group D) (OR, 0.91; 95% CI, 0.39-2.16; P = .834).

CONCLUSIONS

TCAR is safer than TFCAS in patients with simple and advanced arch anatomy. This could be related to the efficiency of flow reversal vs distal embolic protection. The current Centers for Medicare and Medicaid Services decision will likely increase stroke and death outcomes of carotid stenting nationally if multidisciplinary approach and appropriate patient selection are not implemented.

Non-White Patients Have a Higher Risk of Stroke Following Transcarotid Artery Revascularization

INTRODUCTION

Carotid artery revascularization has traditionally been performed by either a carotid endarterectomy or carotid artery stent. Large data analysis has suggested there are differences in perioperative outcomes with regards to race, with non-White patients (NWP) having worse outcomes of stroke, restenosis and return to the operating room (RTOR). The introduction of transcarotid artery revascularization (TCAR) has started to shift the paradigm of carotid disease treatment. However, to date, there have been no studies assessing the difference in postoperative outcomes after TCAR between racial groups.

METHODS

All patients from 2016 to 2021 in the Vascular Quality Initiative who underwent TCAR were included in our analysis. Patients were split into two groups based on race: individuals who identified as White and a second group that comprised all other races. Demographic and clinical variables were compared using Student's t-Test and chi-square test of independence. Logistic regression analysis was performed to determine the impact of race on perioperative outcomes of stroke, myocardial infarction (MI), death, restenosis, RTOR, and transient ischemic attack (TIA).

RESULTS

The cohort consisted of 22,609 patients: 20,424 (90.3%) White patients and 2185 (9.7%) NWP. After adjusting for sex, diabetes, hypertension, coronary artery disease, history of prior stroke or TIA, symptomatic status, and high-risk criteria at time of TCAR, there was a significant difference in postoperative stroke, with 63% increased risk in NWP (odds ratio = 1.63, 95% confidence interval: 1.11-2.40, P = 0.014). However, we found no significant difference in the odds of MI, death, postoperative TIA, restenosis, or RTOR when comparing NWP to White patients.

CONCLUSIONS

This study demonstrates that NWP have increased risk of stroke but similar outcomes of death, MI, RTOR and restenosis following TCAR. Future studies are needed to elucidate and address the underlying causes of racial disparity in carotid revascularization.

One Puncture, Two Solutions: Simultaneous Carotid and Iliac Artery Stenting

An 81-year-old man with asymptomatic severe carotid artery stenosis and symptomatic iliac artery stenosis underwent simultaneous carotid artery stenting (CAS) and iliac artery percutaneous transluminal angioplasty and stenting. The procedure involved transfemoral access, balloon angioplasty, and stenting of the right iliac artery, followed by CAS of the right carotid artery. Similar procedures were performed later on the left iliac and carotid arteries. The patient was discharged with no neurological deficits and remained asymptomatic at a six-month follow-up. Simultaneous CAS and iliac artery stenting were feasible and effective in patients with concurrent severe carotid and iliac artery stenosis, providing a comprehensive revascularization strategy for patients with complex atherosclerotic disease.

Learning curve of transfemoral carotid artery stenting in the Vascular Quality Initiative registry

OBJECTIVE

With the recent expansion of the Centers for Medicare and Medicaid Services coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. Because approximately 30% of perioperative strokes/deaths post-CAS occur after discharge, appropriate thresholds for in-hospital event rates have been suggested to be <4% for symptomatic and <2% for asymptomatic patients. This study evaluates the tfCAS learning curve using Vascular Quality Initiative (VQI) data.

METHODS

We identified VQI patients who underwent tfCAS between 2005 and 2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. The primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/myocardial infarction (MI), 30-day mortality, in-hospital stroke/transient ischemic attack (stroke/TIA), and access site complications. The relationship between outcomes and procedure counts was analyzed using the Cochran-Armitage test and a generalized linear model with restricted cubic splines. Our results were then validated using a generalized estimating equations model to account for the variability between physicians.

RESULTS

We analyzed 43,147 procedures by 2476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2%-1.7%), in-hospital stroke/death/MI (5.8%-1.7%), 30-day mortality (4.6%-2.8%), in-hospital stroke/TIA (5.0%-1.1%), and access site complications (4.1%-1.1%) as physician experience increased (all P values < .05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1%-1.6%), in-hospital stroke/death/MI (2.6%-1.6%), 30-day mortality (1.7%-0.4%), and in-hospital stroke/TIA (2.8%-1.6%) with increasing physician experience (all P values <.05). The in-hospital stroke/death rate remained above 2% until 13 procedures.

CONCLUSIONS

In-hospital stroke/death and 30-day mortality rates after tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. Nevertheless, a substantially high rate of in-hospital stroke/death was found in physicians' first 25 procedures. With the recent Centers for Medicare and Medicaid Services coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased postoperative complications.

Use of Glycoprotein IIb-IIIa Inhibitors in Patients Undergoing Carotid Artery Stenting in the Vascular Quality Initiative

BACKGROUND

Antiplatelet therapies with thromboxane inhibitors and adenosine 5'-diphosphate antagonists have been widely used following carotid artery stenting (CAS). However, these therapies may not apply to patients who are intolerant or present acutely. Glycoprotein IIb/IIIa inhibitors (GPI) are a proposed alternative therapy in these patients; however, their use has been limited due to concerns of increased risk for intracranial bleeding. Thus, this study aims to assess the safety profile of GPI in patients undergoing CAS.

METHODS

All patients undergoing CAS in the Society of Vascular Surgery - Vascular Quality Initiative database from 2012 to 2021 was included and grouped into GPI versus non-GPI therapy (control). The primary outcome was in-hospital stroke or death, and secondary outcomes included in-hospital stroke/transient ischemic attack (TIA), death, myocardial infarction, and intracranial hemorrhage (ICH)/seizure. Patients were stratified by surgical approach (Transcarotid artery revascularization using flow reversal (TCAR) and transfemoral carotid artery stenting), and stepwise backward logistic regression analysis was conducted to evaluate major primary and secondary outcomes.

RESULTS

A total of 50,628 patients underwent carotid revascularization. Of these, 4.4% of the patients received GPI. Mean age was similar between control versus GPI (71.35(9.67) vs. 71.36(10.20) years). Compared to the control group, patients who receive GPI are less likely to be on optimal medical therapy, including aspirin (83.0% vs. 88.1%), P2Y12 inhibitor (73.0% vs. 82.7%), and statin (82.3% vs. 86.0%) (All P < 0.05). In addition, patients in the GPI group were more likely to undergo TCAR for carotid revascularization (52.2% vs. 48.4%) for emergent/urgent (29.4% vs. 16.8%) and symptomatic indications (55.5% vs. 49.7%) (All P < 0.001). After stratifying by surgical approach, if patients underwent TFCAS and received a GPI, they were at increased odds of developing stroke/death (1.77(1.25-2.51)), death (odds ratio (OR) (95% CI): 1.67(1.07-2.61)), stroke/TIA (OR (95% confidence interval (CI)): 1.65(1.09-2.51)), and ICH/seizure (OR (95% CI): 2.13(1.23-3.68)) (All P < 0.05). No difference was seen in outcomes between the 2 groups if undergoing TCAR.

CONCLUSIONS

Patients who receive GPI were more likely to be symptomatic at presentation and less likely to be medically optimized before their carotid revascularization. Transfemoral access in patients receiving GPI was associated with increased odds of morbidity and mortality. However, this was not observed if undergoing TCAR. TCAR can be considered for its overall favorable results in high-risk patients who are not medically optimized.

The Evolution of Current Management for Carotid Artery Bifurcation Disease

Options for treatment of symptomatic carotid bifurcation disease include carotid endarterectomy (CEA) and carotid artery stenting (CAS). While over the years CEA has established itself as the gold standard for carotid artery revascularization, results from recent trials have shown CAS to be safe and effective in selected patients. This review details the evolution of carotid artery bifurcation disease by highlighting key clinical trials.

Thrombectomy and stenting of pseudoaneurysm from transcarotid artery revascularization

Background

Transcarotid artery revascularization (TCAR) is becoming an increasingly popular treatment of carotid stenosis. Despite this rapid adoption, little in the literature describes the associated complications of this procedure.

Case Description

We report a case of a left M1 large-vessel occlusion following treatment of symptomatic, high-grade carotid stenosis with a TCAR procedure approximately three weeks earlier. The initial angiography demonstrated a pseudoaneurysm in the left common carotid artery at the site of TCAR access with a distal clot in the carotid stent. The clot within the stent was aspirated, and a mechanical thrombectomy was performed with a combination of a stent-retriever and aspiration catheter for thrombolysis in cerebral infarction 2B revascularization.

Conclusion

The TCAR procedure offers a novel method for revascularization of carotid lesions; it does include its complications. While generally safe, access site complications such as pseudoaneurysms can always occur. Knowledge of this risk allows for appropriate surveillance and management should it occur.

Long-term outcomes of carotid endarterectomy vs transfemoral carotid stenting in a Medicare-matched database

BACKGROUND

Carotid endarterectomy (CEA) is associated with lower risk of perioperative stroke compared with transfemoral carotid artery stenting (TFCAS) in the treatment of carotid artery stenosis. However, there is discrepancy in data regarding long-term outcomes. We aimed to compare long-term outcomes of CEA vs TFCAS using the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database.

METHODS

We assessed patients undergoing first-time CEA or TFCAS in Vascular Quality Initiative Vascular-Vascular Implant Surveillance and Interventional Outcomes Network from January 2003 to December 2018. Patients with prior history of carotid revascularization, nontransfemoral stenting, stenting performed without distal embolic protection, multiple or nonatherosclerotic lesions, or concomitant procedures were excluded. The primary outcome of interest was all-cause mortality, any stroke, and a combined end point of death or stroke. We additionally performed propensity score matching and stratification based on symptomatic status.

RESULTS

A total of 80,146 carotid revascularizations were performed, of which 72,615 were CEA and 7531 were TFCAS. CEA was associated with significantly lower risk of death (57.8% vs 70.4%, adjusted hazard ratio [aHR], 0.46; 95% confidence interval [CI], 0.41-0.52; P < .001), stroke (21.3% vs 26.6%; aHR, 0.63; 95% CI, 0.57-0.69; P < .001) and combined end point of death and stroke (65.3% vs 76.5%; HR, 0.49; 95% CI, 0.44-0.55; P < .001) at 10 years. These findings were reflected in the propensity-matched cohort (combined end point: 34.6% vs 46.8%; HR, 0.53; 95% CI, 0.46-0.62) at 4 years, as well as stratified analyses of combined end point by symptomatic status (asymptomatic: 63.2% vs 74.9%; HR, 0.49; 95% CI, 0.43-0.58; P < .001; symptomatic: 69.9% vs 78.3%; HR, 0.51; 95% CI, 0.45-0.59; P < .001) at 10 years.

CONCLUSIONS

In this analysis of North American real-world data, CEA was associated with greater long-term survival and fewer strokes compared with TFCAS. These findings support the continued use of CEA as the first-line revascularization procedure.

"TCAR or nothing": the only options for some complex carotid stenosis

Transcervical carotid artery revascularization has emerged as an alternative to carotid endarterectomy and transfemoral carotid artery stenting. We present four cases for which we believe transcervical carotid artery revascularization was the only option to treat the lesions. Each case presented with specific technical challenges that were overcome by intraoperative planning that allowed for safe deployment of the Enroute stent (Silk Road Medical) with resolution of each patient's stenosis.

The intracranial effects of flow reversal during transcarotid artery revascularization

Background

This study aimed to assess intraoperative cerebral hemodynamic responses and embolic events during transcarotid artery revascularization via transcranial Doppler, near-infrared spectroscopy, and bispectral index monitoring.

Methods

Twelve patients (7 males, 5 females; mean age: 72.8±9.0 years; range, 63 to 91 years) undergoing transcarotid artery revascularization with simultaneous transcranial Doppler, near-infrared spectroscopy, and bispectral index monitoring were analyzed in this retrospective study between September 2017 and December 2019. The mean flow velocity and pulsatility index of the middle cerebral artery, alongside near-infrared spectroscopy and bispectral index values, before flow reversal, during flow reversal, and after flow reversal phases were investigated. The presence and frequency of high-intensity transient signals were recorded to evaluate embolic incidents.

Results

Significant reductions in middle cerebral artery mean flow velocity were noted during flow reversal (40.58±10.57 cm/sec to 20.58±14.34 cm/sec, p=0.0004), which subsequently returned to and exceeded baseline values after flow reversal cessation (53.33±17.69 cm/sec, p=0.0005). Near-infrared spectroscopy (71±4.4% to 66±6.2%) and bispectral index (45.71±8.5 to 40.14±8.1) values mirrored these hemodynamic changes, with notable decreases during flow reversal, and recoveries after flow reversal. The highest concentration of high-intensity transient signals was observed during stent deployment, signifying a critical embolic phase. No perioperative neurological complications or other significant adverse events were documented.

Conclusion

Transcranial Doppler, near-infrared spectroscopy, and bispectral index effectively monitor cerebral hemodynamics and embolic potential during transcarotid artery revascularization, providing real-time data crucial for optimizing perioperative management. These findings underscore the clinical value of multimodal monitoring in improving patient outcomes in transcarotid artery revascularization procedures.

Feasibility and Intermediate Results of Transcarotid Revascularization with a Prosthetic Conduit

BACKGROUND

Transcarotid artery revascularization (TCAR) is a hybrid technique with excellent initial outcomes. The technical success and safety of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet anatomic criteria and therefore are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy via the adoption of a prosthetic arterial conduit.

METHODS

A single-center retrospective study of patients with critical carotid artery stenosis who underwent TCAR via a prosthetic conduit between June 2019 and October 2021 was performed. All patients in the study were considered high-risk for carotid endarterectomy based on anatomic features, such as restenosis post-carotid endarterectomy and neck radiation. Unfavorable CCA anatomy was defined as a clavicle to carotid bifurcation distance <5 cm, a CCA diameter <6 mm, and/or significant atherosclerotic disease at the intended arterial access site. The primary outcome of interest was technical success. Secondary outcomes included perioperative complications, intermediate and long-term patency, intermediate and long-term stroke and/or mortality and in-hospital length of stay. Follow-up ranged from 1 to 29 months.

RESULTS

Eight patients underwent 10 TCAR procedures via a prosthetic conduit. A total of 2 procedures (20%) were performed on female patients and 8 procedures (75%) were performed on male patients. The mean age was 65 years old (standard deviation 11 years). Technical success was 100%. The 30-day ipsilateral stroke rate was 0%. The 30-day patency was 90%. There was no re-exploration for hemorrhage and 30 day mortality was 0%.

CONCLUSIONS

TCAR is an excellent option for carotid artery revascularization. Unfavorable CCA anatomy has limited its applicability. TCAR via a prosthetic conduit has the potential to expand eligibility for this promising therapy.

Modality-specific outcomes of patients undergoing carotid revascularization in the setting of recent myocardial infarction

OBJECTIVE

Recent myocardial infarction (MI) represents a real challenge in patients requiring any vascular procedure. There is currently a lack of data on the effect of preoperative MI on the outcomes of carotid revascularization methodology (carotid enterectomy [CEA], transfemoral carotid artery stenting [TFCAS], or transcarotid artery revascularization [TCAR]). This study looks to identify modality-specific outcomes for patients with recent MI undergoing carotid revascularization.

METHODS

Data was collected from the Vascular Quality Initiative (2016-2022) for patients with carotid stenosis in the United States and Canada with recent MI (<6 months) undergoing CEA, TFCAS, or TCAR. In-hospital outcomes after TFCAS vs CEA and TCAR vs CEA were compared. TCAR vs TFCAS were compared in a secondary analysis. We used logistic regression models to compare the outcomes of these three procedures in patients with recent MI, adjusting for potential confounders. Primary outcomes included 30-day in-hospital rates of stroke, death, and MI. Secondary outcomes included stroke/death, stroke/death/MI, postoperative hypertension, postoperative hypotension, prolonged length of stay (>2 days), and 30-day mortality.

RESULTS

The final cohort included 1217 CEA (54.2%), 445 TFCAS (19.8%), and 584 TCAR (26.0%) cases. Patients undergoing CEA were more likely to have prior coronary artery bypass graft/percutaneous coronary intervention and to use anticoagulant. Patients undergoing TFCAS were more likely to be symptomatic, have prior congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and undergo urgent operations. Patients undergoing TCAR were more likely to have higher rates of American Society of Anesthesiologists class IV to V, P2Y12 inhibitor, and protamine use. In the univariate analysis, CEA was associated with a lower rate of ipsilateral stroke (P = .079), death (P = .002), and 30-day mortality (P = .007). After adjusting for confounders, TFCAS was associated with increased risk of stroke/death (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.36-5.35; P = .005) and stroke/death/MI (aOR, 1.67; 95% CI, 1.07-2.60; P = .025) compared with CEA. However, TCAR had similar outcomes compared with CEA. Both TFCAS and TCAR were associated with increased risk of postoperative hypotension (aOR, 1.62; 95% CI, 1.18-2.23; P = .003 and aOR, 1.74; 95% CI, 1.31-2.32; P ≤ .001, respectively) and decreased risk of postoperative hypertension (aOR, 0.59; 95% CI, 0.36-0.95; P = .029 and aOR, 0.50; 95% CI, 0.36-0.71; P ≤ .001, respectively) compared with CEA.

CONCLUSIONS

Although recent MI has been established as a high-risk criterion for CEA and an approved indication for TFCAS, this study showed that CEA is safer in this population with lower risk of stroke/death and stroke/death/MI compared with TFCAS. TCAR had similar stroke/death/MI outcomes in comparison to CEA in patients with recent MI. Further prospective studies are needed to confirm our findings.

Automatic 1-year follow-up appointment creation and reminders can improve long-term follow-up after carotid revascularization

BACKGROUND

Long-term follow-up (LTFU) following carotid revascularization is important for post-surgical care, stroke risk optimization and post-market surveillance of new technologies.

METHODS

We instituted a quality improvement project to improve LTFU rates for carotid revascularizations (primary outcome) by scheduling perioperative and one-year follow-up appointments at time of surgery discharge. A temporal trends analysis (Q1 2019 through Q1 2022), multivariable regression, and interrupted time series (ITS) were performed to compare pre-post intervention LTFU rates.

RESULTS

269 consecutive patients were included (151 pre-intervention, 118 post-intervention; mean 71 ​± ​12 years-old, 39% female, 77% White). The overall LTFU rate improved (64.9%-78.8%; P ​= ​0.013) after the intervention. After controlling for patient factors, procedures performed after the intervention were associated with increased odds of being seen for 1-year follow-up (OR: 2.2 95%CI: 1.2-4.0). Quarterly ITS analysis corroborated this relationship (P ​= ​0.01).

CONCLUSIONS

Time-of-surgery appointment creation and automated patient reminders can improve LTFU rates following carotid revascularizations.

Neck radiation is not associated with increased risk of perioperative adverse events after transcarotid artery revascularization or transfemoral carotid artery stenting

OBJECTIVE

It is unclear whether patients with prior neck radiation therapy (RT) are at high risk for carotid artery stenting (CAS). We aimed to delineate 30-day perioperative and 3-year long-term outcomes in patients treated for radiation-induced stenotic lesions by the transfemoral carotid artery stenting (TFCAS) or transcarotid artery revascularization (TCAR) approach to determine comparative risk and to ascertain the optimal intervention in this cohort.

METHODS

Data were extracted from the Vascular Quality Initiative CAS registry for patients with prior neck radiation who had undergone either TCAR or TFCAS. The Student t-test and the χ2 test were used to compare baseline patient characteristics. Multivariable logistic regression and Cox Hazard Proportional analysis were used to compare perioperative and long-term differences between patients with and without prior neck radiation following TCAR and TFCAS. Kaplan-Meier estimator was used to determine the incidence of 3-year adverse events.

RESULTS

A total of 72,656 patients (TCAR, 40,879; TFCAS, 31,777) were included in the analysis. Of these, 4151 patients had a history of neck radiation. Patients with a history of neck radiation were more likely to be younger, white, and have fewer comorbidities than patients with no neck radiation history. After adjustment for confounding factors, there was no difference in relative risk of 30-day perioperative stroke (P = .11), death (P = .36), or myocardial infarction (MI) (P = .61) between TCAR patients with or without a history of neck radiation. The odds of stroke/death (P = .10) and stroke/death/MI (P = .07) were also not statistically significant. In patients with prior neck radiation, TCAR had lower odds for in-hospital stroke/death/MI (odds ratio, 0.59; 95% confidence interval [CI], 0.35-0.99; P = .05) and access site complications than TFCAS. At year 3, patients with prior neck radiation had an increased hazard for mortality after TCAR (hazard ratio [HR], 1.24; 95% CI, 1.02-1.51; P = .04) and TFCAS (HR, 1.33; 95% CI, 1.12-1.58; P = .001). Patients with prior neck radiation also experienced an increased hazard for reintervention after TCAR (HR, 2.16; 95% CI, 1.45-3.20; P < .001) and TFCAS (HR, 1.67; 95% CI, 1.02-2.73; P<.001).

CONCLUSIONS

Patients with prior neck radiation had a similar relative risk of 30-day perioperative adverse events as patients with no neck radiation after adjustment for baseline demographics and disease characteristics. In these patients, TCAR was associated with reduced odds of perioperative stroke/death/MI as compared with TFCAS. However, patients with prior neck radiation were at increased risk for 3-year mortality and reintervention.

A single-center experience of 30-day perioperative and one year clinical outcomes of transcarotid artery revascularization in 100 consecutive patients

BACKGROUND

Transcarotid Artery Revascularization (TCAR) using the ENROUTE system (Silk Road) has been proposed as a safe and effective alternative to both carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS). Two large registries (ROADSTER 1 and ROADSTER 2) have shown that TCAR has acceptable/low rates of perioperative stroke/death. This study will analyze the 30-day perioperative and 1-year clinical outcomes from a single-center.

PATIENT POPULATION AND METHODS

This is a retrospective analysis of prospectively collected data from SVS/VQI TCAR surveillance project (TSP) of 100 consecutive patients (102 TCAR procedures) done in our institution. These procedures were done for high-risk patients for CEA, which included anatomical (previous CEA, high cervical lesion, neck radiation, stoma, arch type, etc.), physiological (CHF, severe coronary artery disease, COPD on O2 therapy, etc.) and combined anatomical/physiological reasons. These procedures were done by vascular surgeons after receiving the appropriate training. The perioperative stroke, death, and MI rates were analyzed. Kaplan Meyer analysis was used to estimate rate of freedom from stroke/death and the incidence of ≥50% and ≥80% in-stent restenosis at 1 year.

RESULTS

100 consecutive high-risk patients for CEA included: 38% anatomical, 44% physiological, and 18% combined anatomical and physiological reasons. The mean age was 72.5 years (range 52-90 years). Indications for TCAR were 34% for symptomatic lesions (TIA/stroke) and 66% for asymptomatic lesions. Mean ipsilateral treated stenosis was 80.4%. Contralateral ≥50% stenosis/occlusion was present in 31% of patients. Technical success rate was 100%. 92% had pre-stenting PTA and 26% had post-stenting PTA. The mean flow reversal time was 8.5 min (range 3-26 min). The 30-day perioperative stroke rate was 2.9% (1/67, 1.5% for asymptomatic patients), the stroke/death rate was 2.9%, and stroke/death and MI rate was 3.9% (4/102). Other perioperative complications included cranial nerve injury 3/102 (2.9%), carotid artery dissection (2%), and major hematoma (necessitated operation evacuation) (5.9%). Freedom from stroke rates and stroke/death rates at 1 year were: 90% and 89%. Freedom from ≥50% and ≥80% in-stent restenosis rates at 1 year were 82% and 90%, respectively. None of these restenosis were symptomatic except two (2/13). Freedom from reintervention rate at 1 year was 98%.

CONCLUSION

Although the perioperative events were somewhat higher than what has been reported in previous registries, TCAR for patients who are high-risk for CEA has a low perioperative stroke and stroke/death rates with satisfactory outcome at 1 year. Further long-term data is probably needed to verify long-term outcome.

Neuroprotective association of preoperative renin-angiotensin system blocking agents use in patients undergoing carotid interventions

OBJECTIVE

The optimal medical management strategy in the periprocedural period for patients undergoing carotid artery interventions is not well described. Renin-angiotensin-system blocking (RASB) agents are considered to be among the first line anti-hypertensive agents; however, their role in the perioperative period is unclear. The objective of this study was to examine the relationship between the use of RASB agents on periprocedural outcomes in patients undergoing carotid interventions-carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR).

METHOD

The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA, and TCAR between 2003 and 2020. Patients were stratified into two groups based upon their use of RASB agents in the periprocedural period. The primary endpoint was periprocedural neurologic events (including both strokes and transient ischemic attacks (TIAs)). The secondary endpoints were peri-procedural mortality and significant cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure.

RESULTS

Over 150,000 patients were included in the analysis: 13,666 patients underwent TCAR, 13,811 underwent CAS, and 125,429 underwent CEA for carotid artery stenosis. Overall, 52.2% of patients were maintained on RASB agents. Among patients undergoing CEA, patients on RASB agents had a significantly lower rate of periprocedural neurologic events (1.7% versus 2.0%, p =0.001). The peri-procedural neurological event rate in the TCAR cohort was similarly reduced in those treated with RASB agents, but did not reach statistical significance (2.0% vs 2.4%, p = 0.162). Among patients undergoing CAS, there was no difference in perioperative neurologic events between the RASB treated and untreated cohorts (3.4% vs 3.2%, p = 0.234); however, the use of RASB agents was significantly associated with lower mortality (1.2% vs 1.7%, p =0.001) with CAS. The use of preoperative RAS-blocking agents did not appear to affect the overall rates of adverse cardiac events with any of the three carotid intervention types, or periprocedural mortality following CEA or TCAR. On multivariable analysis, the use of RAS-blocking agents was independently associated with lower rates of post-procedural neurologic events in patients undergoing CEA (OR 0.819, CI 0.747-0.898; p = 0.01) and TCAR (OR 0.869, CI 0.768-0.984; p = 0.026), but not in those undergoing CAS (OR 0.967, CI 0.884-1.057; p = 0.461).

CONCLUSION

The use of peri-procedural RASB agents was associated with a significantly decreased rate of neurologic events in patients undergoing both CEA and TCAR. This effect was not observed in patients undergoing CAS. As carotid interventions warrant absolute minimization of perioperative complications in order to provide maximum efficacy with regard to stroke protection, the potential neuro-protective effect associated with RASB agents use following CEA and TCAR warrants further examination.

Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization

OBJECTIVE

Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR.

METHODS

We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded.

RESULTS

During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients.

CONCLUSIONS

Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.

Prospective evaluation of acute cerebral injury by DW-MRI following transcarotid artery revascularization using a double-layer micromesh stent

BACKGROUND

Transcervical carotid artery revascularization (TCAR) has demonstrated a low overall stroke rate in carotid artery stenting (CAS). Furthermore, the use of a double-layer micromesh stent is expected to reduce embolization and plaque prolapse. The combination of TCAR and the double layer stent may lead to improved results compared to previously reported outcomes. The objective of this study is to present the findings of a prospective study including patients treated with the Roadsaver stent and TCAR.

METHODS

Between January 2017 and May 2022, 85 patients were enrolled. Every patient underwent TCAR with the Roadsaver stent. As per our protocol, a neurological examination and an ultrasound were performed within 24 hours before and after the procedure, and again 30 days after. A diffusion-weighted magnetic resonance imaging (DW-MRI) was conducted 24 hours before the procedure and 48-72 hours after the procedure. The primary endpoint was the detection of new ischemic lesions on postoperative DW-MRI. The secondary endpoint was a composite of all strokes, death, and myocardial infarction within 30 days.

RESULTS

Sixty-four patients (75.29%) were symptomatic, out of which 25 were treated within 14 days of the onset of the symptoms. Pre and postprocedural DW-MRI were performed in 83 patients. Postprocedural lesions were found in nine patients (10.84%). There were no strokes or death within 30 days, but two patients experienced a myocardial infarction.

CONCLUSIONS

Our study suggests that the use of TCAR and the Roadsaver stent could be a safe alternative to carotid endarterectomy because it entails a low incidence of cerebral embolization, even in recently symptomatic and elderly patients.

Impact of Physician Experience on Stroke or Death Rates in Transfemoral Carotid Artery Stenting: Insights from the Vascular Quality Initiative

Objective

With the recent expansion of the Centers for Medicare and Medicaid Services (CMS) coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. This study evaluates the tfCAS learning curve using VQI data.

Methods

We analyzed tfCAS patient data from 2005-2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. Primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/MI, 30-day mortality, and in-hospital stroke/TIA. The relationship between outcomes and procedure counts was analyzed using Cochran Armitage test and a generalized linear model with restricted cubic splines, validated using generalized estimating equations.

Results

We analyzed 43,147 procedures by 2,476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2% to 1.7%), in-hospital stroke/death/MI (5.8% to 1.7%), 30-day mortality (4.6% to 2.8%), in-hospital stroke/TIA (5.0% to 1.1%) (all p-values<0.05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1% to 1.6%), in-hospital stroke/death/MI (2.6% to 1.6%), 30-day mortality (1.7% to 0.4%), and in-hospital stroke/TIA (2.8% to 1.6%) with increasing physician experience (all p-values<0.05). The in-hospital stroke/death rate remained above 2% until 13 procedures.

Conclusions

In-hospital stroke/death and 30-day mortality rates post-tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. With the recent CMS coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased post-operative complications.

Perioperative Outcomes in Transcarotid Artery Revascularization Versus Carotid Endarterectomy or Stenting Nationwide

BACKGROUND AND OBJECTIVES

Transcarotid artery revascularization (TCAR) is a newer treatment for carotid stenosis where the carotid artery is accessed directly in the neck for stenting. It is less invasive than carotid endarterectomy (CEA) and has less embolic potential than carotid artery stenting (CAS), but population-level utilization of TCAR and outcomes are currently unknown. Our study compares outcomes of TCAR with those of CEA and CAS.

METHODS

The National Inpatient Database was used for years 2015 to 2019. A multivariate logistic regression model was used to compare CEA, CAS, and TCAR outcomes with age, sex, race, hospital teaching status, symptomatic carotid disease status, side of procedure, intraoperative monitoring, and the weighted Elixhauser comorbidity score as covariates.

RESULTS

TCAR comprised 0.69% of these procedures in 2016, rising to 1.35% in 2019. The inpatient rates of death, stroke, and myocardial infarction for TCAR were 0.63% (95% confidence interval: 0.36%, 1.06%), 0.42% (0.21%, 0.80%), and 1.46% (1.04%, 2.05%), respectively. Compared with CEA, TCAR had statistically insignificant difference odds of death, odds ratio (95% CI) for stroke was 0.47 (0.25, 0.87), and for myocardial infarction, it was 0.66 (0.37, 0.94). Compared with CAS, for TCAR, the odds ratio for death was 0.41 (0.24, 0.71), and for stroke, it was 0.48 (0.26, 0.91).

CONCLUSION

TCAR is underutilized relative to other revascularization techniques yet has favorable outcomes compared with CEA and CAS. TCAR may be preferred to CAS in patients not surgical candidates for CEA and has a less invasive possibility for those eligible for CEA.

Propensity-Score Matched Analysis of Three Years Survival of Trans Carotid Artery Revascularization Versus Carotid Endarterectomy in the Vascular Quality Initiative Medicare-Linked Database

OBJECTIVE

Carotid endarterectomy (CEA) remains the gold standard procedure for carotid revascularization. Transfemoral carotid artery stenting (TFCAS) was introduced as a minimally invasive alternative procedure in patients who are at high risk for surgery. However, TFCAS was associated with an increased risk of stroke and death compared to CEA.

BACKGROUND

Transcarotid artery revascularization (TCAR) has outperformed TFCAS in several prior studies and has shown similar perioperative and 1-year outcomes compared with CEA. We aimed to compare the 1-year and 3-year outcomes of TCAR versus CEA in the Vascular Quality Initiative (VQI)-Medicare-Linked [Vascular Implant Surveillance and Interventional Outcomes Network (VISION)] database.

METHODS

The VISION database was queried for all patients undergoing CEA and TCAR between September 2016 to December 2019. The primary outcome was 1-year and 3-year survival. One-to-one propensity-score matching (PSM) without replacement was used to produce 2 well-matched cohorts. Kaplan-Meier estimates, and Cox regression was used for analyses. Exploratory analyses compared stroke rates using claims-based algorithms for comparison.

RESULTS

A total of 43,714 patients underwent CEA and 8089 patients underwent TCAR during the study period. Patients in the TCAR cohort were older and were more likely to have severe comorbidities. PSM produced two well-matched cohorts of 7351 pairs of TCAR and CEA. In the matched cohorts, there were no differences in 1-year death [hazard ratio (HR)=1.13; 95% CI, 0.99-1.30; P =0.065]. At 3-years, TCAR was associated with slight increased risk of death (HR=1.16; 95% CI, 1.04-1.30; P =0.008). When stratifying by initial symptomatic presentation, the increased 3-year death associated with TCAR persisted only in symptomatic patients (HR=1.33; 95% CI, 1.08-1.63; P =0.008). Exploratory analyses of postoperative stroke rates using administrative sources suggested that validated measures of claims-based stroke ascertainment are necessary.

CONCLUSIONS

In this large multi-institutional PSM analysis with robust Medicare-linked follow-up for survival analysis, the rate of death at 1 year was similar in TCAR and CEA regardless of symptomatic status. The slight increase in the risk of 3-year death in symptomatic patients undergoing TCAR is likely confounded by more severe comorbidities despite matching. A randomized controlled trial comparing TCAR to CEA is necessary to further determine the role of TCAR in standard-risk patients requiring carotid revascularization.

Society for Vascular Surgery duplex ultrasound surveillance guidelines are safe and cost effective for transcarotid artery revascularization

BACKGROUND

Carotid duplex ultrasound (CDUS) examination is used in the long-term surveillance after transcarotid artery revascularization (TCAR). The objective of this study was to evaluate the usefulness and cost effectiveness of post-TCAR CDUS surveillance regimens in monitoring for in-stent restenosis (ISR) and associated stroke risk at a single-center community institution.

METHODS

CDUS data were collected retrospectively from patients who had undergone TCAR between January 2017 and January 2023. ISR >50% was defined as a peak systolic velocity (PSV) of >220 cm/s and an internal carotid artery (ICA) to common carotid velocity ratio of >2.7. ISR >80% was defined as a PSV of >340 cm/s and an ICA/common carotid artery ratio of >4.15. Study outcomes included incidences of ISR, reintervention, transient ischemic attacks (TIAs), strokes, and mortality. A Kaplan-Meier survival analysis was done to calculate the rates of freedom from ISR.

RESULTS

During the study period, 108 TCAR stents were deployed in 104 patients. Eight patients were excluded in analysis or lost to follow-up. Preoperatively, 62% of patients had >80% stenosis, and 39% were symptomatic. No intraprocedural complications were noted. One patient suffered an immediate postoperative dissection. Eight stents (8%) experienced ISR progression from <50% to >50%. Three of the eight had further ISR progression to >80%. One patient had high-grade ISR and a contralateral ICA occlusion that warranted reintervention. There were no occurrences of postoperative TIAs, strokes, or TCAR-related deaths. Rates of freedom from ISR progression from <50% to >50% were 97.4%, 95.9%, 90.9%, 88.2%, and 88.2% at 6, 12, 24, 36, and 42 months, respectively. Rates of freedom from ISR >80% were 100%, 100%, 98.5%, 95.5%, and 95.5% at the same time points. Patients with >50% ISR tended to be females with hyperlipidemia. In addition, they had higher average lesion lengths and lower rates of postdilation balloon angioplasty. The 5-year estimated surveillance cost in this cohort using the Society for Vascular Surgery 2022, and 2018 guidelines, as well as our current protocol would be $113,853, $221,382, and $193,207, respectively.

CONCLUSIONS

This study revealed a low incidence of ISR progression, as well as no TIA, stroke, or TCAR-related deaths, highlighting the safety and efficacy of TCAR. Post-TCAR CDUS examination using the updated Society for Vascular Surgery guidelines are safe and cost effective. Patients with contralateral occlusion or stenosis, or who have significant risk factors, should have more frequent surveillance regimens.

Use of a prosthetic conduit for stent delivery in transcarotid artery revascularization for patients with unfavorable anatomy

Transcarotid artery revascularization (TCAR) provides a safe alternative to carotid endarterectomy. The anatomic requirements include a 5-cm minimum clavicle to carotid bifurcation distance for sheath access proximal to the lesion. In the present report, we describe our experience with conduit use for patients not meeting that requirement. Patients undergoing elective TCAR with a conduit from 2021 to 2022 were retrospectively identified. After carotid artery exposure, a 6-mm prosthetic graft was anastomosed to the common carotid artery in an end-to-side fashion. After stent delivery, the conduit was ligated and oversewn. The patient demographics, procedural details, and outcomes were recorded and compared with our nonconduit TCAR experience. A total of 11 patients (64% male; age, 75 ± 5 years) underwent TCAR with a conduit, 5 (46%) for symptomatic disease, and 77 patients underwent TCAR with no conduit, 52 (60%) with symptomatic disease (P = .50). Other than a higher rate of prior coronary interventions in the conduit group (55% vs 47%; P = .007), no significant differences were found in age, gender, race, comorbidities, or high risk for carotid endarterectomy criteria. In the conduit group, the average skin to carotid artery depth was 4.2 cm (range, 1.9-6.1 cm). The average clavicle to bifurcation distance was 4.4 cm (range, 3.3-4.9 cm) vs 6.5 cm (range, 3.3-9.7 cm; P = .002) in the nonconduit group. Dacron was the most common conduit material used (73%). No differences were found in the mean procedure times (121 ± 32 vs 129 ± 53 minutes; P = .785) or flow reversal times (14 ± 5 vs 19 ± 13 minutes; P =.989) for the conduit and nonconduit cohorts, respectively. Technical success was achieved in 100% of the conduit and nonconduit cases. Excluding one outlier of a prolonged stay (7 days) for management of unrelated medical issues (gastrostomy tube placement for chronic dysphagia after mass resection and neck radiation), the mean hospital stay was 2 days (1.2 ± 0.4 intensive care unit days) compared with 3.8 ± 5.7 days for our nonconduit cohort (P = .2). Hypotension was the most common reason for delayed discharge for the conduit group (n = 3; 27%). The average follow-up was 2.7 months (range, 1-10 months). For all 11 conduit patients, the stent remained patent without stenosis, thrombus, or pseudoaneurysm at the conduit stump site on surveillance duplex ultrasound. No strokes or complications had occurred at 30 days in the conduit group compared with four strokes or transient ischemic attacks (P = .469) and 18 minor complications in the nonconduit group (P = .091). For patients lacking a sufficient distance between the clavicle and carotid artery bifurcation, a prosthetic conduit facilitates safe use of flow reversal for stent delivery and can be ligated at procedural completion without consequences.

What Is the Role of Transcarotid Artery Revascularization?

Carotid endarterectomy (CEA) is the gold-standard method of carotid revascularization in symptomatic patients with ≥50% and in asymptomatic patients with ≥70% stenosis. Transfemoral carotid artery stenting (TFCAS) has been associated with higher perioperative stroke rates compared to CEA in several studies. On the other hand, transcarotid artery revascularization (TCAR) has outperformed TFCAS in patients who are considered high risk for surgery. There is increasing data that supports TCAR as a safe and efficient technique with outcomes similar to those of CEA, but additional level-one studies are necessary to evaluate the long-term outcomes of TCAR in high- and standard-risk patients.

Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications

Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.

Association of Year of Surgery and Carotid Stenting Outcomes in High-risk Patients, 2015-2021

This cohort study quantifies the yearly trends and outcomes of transcarotid artery revascularization vs transfemoral carotid artery stenting among high-risk patients from 2015 to 2021.

Transcarotid versus transfemoral access for cerebrovascular intervention: protocol for a systematic review and meta-analysis

INTRODUCTION

Cerebrovascular intervention is an excellent option to treat cerebrovascular diseases. Interventional access is a prerequisite and a foundation for cerebrovascular intervention, which is crucial to the success of an intervention. Although transfemoral arterial access (TFA) has become a popular and acceptable method of access for cerebrovascular angiography and intervention in clinical practice, it has some drawbacks that limit the usage in cerebrovascular interventions. Therefore, transcarotid arterial access (TCA) has been developed in cerebrovascular interventions. We aim to conduct a systematic review to compare the safety and efficacy of TCA with TFA for cerebrovascular intervention.

METHODS AND ANALYSIS

In this protocol, Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols were followed. PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials will be searched mainly from 1 January 2004, to the formal search date. Additionally, reference lists and clinical trial registries will be searched. We will include clinical trials with more than 30 participants, which reported the endpoints of stroke, death and myocardial infarction. Two investigators will independently select studies, extract data and assess bias risk. A standardised mean difference with 95% CI will be presented for continuous data, and a risk ratio with 95% CI will be presented for dichotomous data. On inclusion of sufficient studies, subgroup analysis and sensitivity analysis will be conducted. The funnel plot and Egger's test will be used to assess publication bias.

ETHICS AND DISSEMINATION

As only published sources will be used in this review, ethical approval is not required. We will publish the results in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022316468.

Patient Selection Criteria and Procedural Standardization for Carotid Artery Stenting-A Single Center Experience

The gold standard for the treatment of carotid artery stenosis is the carotid endarterectomy (CEA). According to current guidelines, carotid artery stenting (CAS) is an alternative. Randomized control trials (RCTs) show significantly higher rates of peri-interventional strokes after CAS compared to CEA. However, these trials were usually characterized by a great heterogeneity in the CAS procedure. In this retrospective analysis from 2012 to 2020, 202 symptomatic and asymptomatic patients were treated with CAS. Patients were carefully pre-selected according to anatomical and clinical criteria. In all cases, the same steps and material were used. All interventions were performed by five experienced vascular surgeons. Primary endpoints of this study were perioperative death and stroke. Asymptomatic carotid stenosis was present in 77% of the patients and symptomatic in 23%. The mean age was 66 years. The average degree of stenosis was 81%. The CAS technical success rate was 100%. Periprocedural complications occurred in 1.5% of cases, including one major stroke (0.5%) and two minor strokes (1%). The results of this study indicate that through a strict patient selection based on anatomical and clinical criteria, CAS can be performed with very low complication rates. Furthermore, standardization of the materials and the procedure itself is crucial.

Hemodynamic Instability Predicts In-Hospital and One-Year Mortality After TransCarotid Artery Revascularization and TransFemoral Carotid Stenting

OBJECTIVES

Blood pressure fluctuations are a common hemodynamic alteration following carotid artery stenting either with transfemoral (TFCAS) or transcarotid (TCAR) approach and are thought to be related to alteration in baroreceptor function due to angioplasty and stent expansion. These fluctuations are particularly worrisome in the high-risk patient population referred for CAS. This study aims to evaluate the outcomes of patients who required the administration of intravenous blood pressure medication (IVBPmed) for hypotension or hypertension after CAS.

METHODS

All patients undergoing carotid revascularization in the Vascular Quality Initiative (VQI) database between 2016-2021 were included. we compared outcomes of patients who required postoperative IVBPmed to treat hyper- or hypotension with normotensive patients. In-hospital outcomes were compared using multivariable logistic regression. One-year outcomes were assessed using Kaplan-Meier survival and multivariable Cox proportional hazard regression analyses.

RESULTS

We identified 38,510 patients undergoing CAS (57.7% TCAR and 42.3% TFCAS), of which, 30% received IVBPmed for treatment of either postoperative hypertension (12.6%) or hypotension (16.4%). In multivariable analysis, postoperative hypotension was associated with a higher risk of stroke, death, or MI (OR: 3.1, 95%CI (2.6-3.6), P<.001), stroke or death (OR: 2.9, 95%CI (2.4-3.5), P<.001), stroke (OR: 2.6, 95%CI (2.1-3.2), P<.001), death (OR: 3.5, 95%CI (2.6-4.8), P<.001), MI (OR: 4.7, 95%CI (3.3-6.7), P<.001), and bleeding (OR: 1.96, 95%CI (1.4-2.7), P<.001) compared to normotensive patients. Postoperative hypertension was associated with a higher risk of stroke, death, or MI (3.6, 95%CI (3-4.4), P<.001), stroke or death (OR: 3.3, 95%CI (2.7-4.1), P<.001), stroke (OR: 3.7, 95%CI (3-4.7), P<.001), death (OR: 2.7, 95%CI (1.9-3.9), P<.001), MI (OR: 5.7, 95%CI (3.9-8.3), P<.001), and bleeding (OR: 1.9, 95%CI (1.4-2.7), P<.001) compared to normotensive patients.

CONCLUSIONS

Postoperative hypertension or hypotension requiring IVBPmed after CAS is associated with an increased risk of in-hospital stroke, death, MI, and bleeding. Postoperative hypertension is associated with worse survival at one year. This study indicates that the need for IVBPmed after CAS is not benign, therefore, these patients necessitate aggressive perioperative medical management and safe techniques to avoid hypo and hypertension. Close follow-up and continue medical management is needed to maximize these patients' survival.

Impact of Flow Reversal Duration on Neurological Outcomes of Transcarotid Artery Revascularization (TCAR)

BACKGROUNDS

Flow reversal is a key component of transcarotid artery revascularization (TCAR). However, the impact of flow reversal duration on neurological outcomes and the duration of flow reversal which optimizes TCAR's outcomes is not known. We evaluated the association of flow reversal time with the intraoperative and postoperative neurological outcomes of TCAR.

METHODS

We studied all patients undergoing TCAR from September 2016 to October 2021. The exposure of interest was the duration of flow reversal. Multivariable logistic and fractional polynomial models were used to study the impact of flow reversal duration on in-hospital stroke, intraoperative neurological change/intolerance and stroke/death following TCAR and to identify the flow reversal time above which significant perioperative neurological events occur.

RESULTS

The study included 19,462 patients with mean age of 73.4 years who were mostly Caucasian (91%) and male (63%). The mean flow reversal time was 10.7 minutes, and the overall stroke rate was 1.4%. The odds of intraoperative neurological change increased by 3.6% per minute increase in flow reversal time (odds ratio (OR), 1.04; 95%, 1.01-1.06; P < 0.002). Flow reversal duration >10 minutes was associated with 78% increased odds of neurological changes compared to flow reversal duration <10 minutes. There was no significant association between flow reversal duration and stroke, and stroke/death in the first 5 minutes after initiation of flow reversal. The odds of stroke increased by 2.7% per minute increase in flow reversal time >5 minutes (OR, 1.03; 95%, 1.01-1.04; P < 0.001), with flow reversal duration >10 minutes associated with 38% increased odds of stroke compared to flow reversal duration ≤10 minutes (OR, 1.37, 95% confidence interval (CI), 1.09-1.73, P = 0.006). The odds of stroke/death increased by 2.5% per minute increase in flow reversal time >5 minutes (OR, 1.03; 95%, 1.01-1.04; P < 0.001). Flow reversal duration >10 minutes was associated with 25% increased odds of stroke/death compared to flow reversal duration <10 minutes (OR, 1.25, 95% CI, 1.01-1.53, P = 0.038). Symptomatic status did not modify outcomes.

CONCLUSIONS

Our findings suggest that outcomes following TCAR are optimal if the duration of flow reversal is minimized. A clinical cutoff time of 10 minutes is suggested by this study and recommended as a guide. Further studies targeted at the flow reversal component of TCAR are needed to solidify the evidence regarding the clinical effects of temporarily induced retrograde cerebral blood flow during TCAR.

Transcarotid artery revascularization can safely be performed with regional anesthesia and no intensive care unit stay

OBJECTIVE

Hospital resource use is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures is particularly relevant in the setting of the coronavirus disease 2019 pandemic and its impact on staffed intensive care unit (ICU) beds. We sought to evaluate the feasibility of regional anesthesia (RA) and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution.

METHODS

All patients undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management (anticoagulation and antiplatelet therapy, hemodynamic monitoring, neurovascular examination, nursing instructions) was standardized by use of an institutional protocol. Anesthetic modality was at the surgeon's preference. Patients were transferred to a postanesthesia care unit for 2 hours followed by the step-down unit, to a postanesthesia care unit for 4 hours followed by the floor, or alternatively transferred to the ICU. Intravenous (IV) blood pressure medications could be administered at all environments except the floor. Recovery location and length of stay were recorded.

RESULTS

A total of 83 patients underwent TCAR during the study period. The mean age 72 ± 9 years and 59% were male. Thirty-six percent were symptomatic. RA was used for 84% with none converted to general anesthesia (GA) intraoperatively. Postoperatively, 7 of the 83 patients (8%) included in this study were monitored in an ICU overnight (decided perioperatively), mostly for patients with prior neurological symptoms, but in 1 case for postoperative neurological event and in another owing to pulseless electrical activity arrest. Six patients required IV antihypertensives and eight required IV vasoactive support postoperatively. The mean length of ICU stay was 3.7 ± 5.1 days. The mean length of hospital stay for all patients was 2.4 ± 3.3 days. The length of stay for patients undergoing TCAR with GA was higher than those undergoing TCAR with RA (4.2 ± 4.9 days vs 1.4 ± 1.2 days, respectively; P = .066). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of prior stroke, and one respiratory arrest fatality in a frail patient with neck hematoma both of whom were treated under GA.

CONCLUSIONS

Using perioperative care protocols, TCAR can safely be performed while avoiding both GA and an ICU stay in most patients.

TransCarotid Artery Revascularization Can Be Safely Performed in Patients Undergoing Dialysis

BACKGROUND

TransCarotid Artery Revascularization (TCAR) has been effectively performed to prevent stroke in patients with carotid artery stenosis (CS). Prior studies established that TCAR can be safely performed in high-risk patients such as octogenarians, patients with prior carotid endarterectomy (CEA), contralateral occlusion, and heavily calcified lesions. Hemodialysis patients are at an increased risk of exhibiting cardiovascular complications. This study aims to investigate how dialysis may affect TCAR outcomes.

METHODS

The Vascular Quality Initiative (VQI) dataset was queried for patients undergoing TCAR from November 2016 to November 2021. Patients were divided into dialysis and nondialysis groups. The primary outcome was the composite endpoint of in-hospital stroke, death, or myocardial infarction (MI). Secondary outcomes were in-hospital stroke, stroke, or transient ischemic attack (TIA), death, prolonged length of stay (more than 1 day) (PLOS), MI, and stroke or death. Multivariable logistic regression analysis was used to assess in-hospital outcomes. Kaplan-Meier survival and log-rank test were used to assess 1-year survival.

RESULTS

A total of 22,619 patients underwent TCAR during the study period. Of these, 327 patients were undergoing dialysis. On univariable analysis, dialysis patients were associated with a higher risk of mortality compared to nondialysis patients (1.2% vs. 0.6%, P = 0.030). However, after adjusting for potential confounders, this difference did not persist (odd ratio [OR]: 1.99, 95% confidence interval [CI] (0.8-4.9), P = 0.136). Dialysis patients were more likely to experience PLOS (OR: 1.6, 95% CI (1.2-2), P < 0.001). There was no difference between dialysis and nondialysis patients in the risk of stroke or death, stroke, stroke or TIA, MI, and stroke or death, or MI on univariable and multivariable analyses. At 1 year, the overall survival for dialysis versus nondialysis patients was 81.5% vs. 95.5%, P < 0.001.

CONCLUSIONS

To our knowledge, this is the first study to date of dialysis patients who have undergone TCAR. We have shown that there was no difference in the risk of stroke, death, and MI between dialysis and nondialysis patients. Therefore, TCAR can be safely offered to patients undergoing dialysis. Future studies with larger number of patients are warranted to confirm these results.

Quantification of new intracerebral lesions on diffusion-weighted magnetic resonance imaging after transcarotid artery revascularization for treatment of carotid artery stenosis

Objective

Transcarotid artery revascularization (TCAR) has been used with increasing prevalence for treatment of carotid artery stenosis. TCAR holds potential benefits over traditional carotid endarterectomy (CEA) or transfemoral carotid artery stenting by its nature of being less invasive than CEA but more neuroprotective than transfemoral carotid artery stenting. The purpose of this pilot study is to evaluate the effectiveness of the neuroprotection system of TCAR with flow reversal by quantifying the incidence and degree of new intracerebral lesions using diffusion-weighted magnetic resonance imaging (DW-MRI). This study is the first to evaluate these findings in a real-world, high-risk cohort, who would have been excluded from the ROADSTER and ENROUTE transcarotid neuroprotection system DW-MRI studies.

Methods

Patients undergoing unilateral TCAR for symptomatic or asymptomatic severe internal carotid artery disease were eligible and prospectively enrolled in the study. All patients had high risk features, including comorbidities or medications, which excluded them from industry-sponsored DW-MRI trials. Patients underwent a preoperative DW-MRI to obtain a baseline intracerebral evaluation within 1 week of the scheduled surgery. The follow-up DW-MRI occurred within 48 hours postoperatively. The primary outcome was new, acute postoperative lesion(s) identified on DW-MRI. Secondary outcomes include any major stroke, myocardial infarction, or death during hospitalization.

Results

Five consecutive patients underwent TCAR with preoperative and postoperative imaging. All five patients were on dual antiplatelet therapy before their procedure and verified to be therapeutic on these agents. All patients underwent a right-sided TCAR and three were symptomatic as the indication for their procedure. All five patients demonstrated chronic lesions on the preoperative DW-MRI. Technical success was achieved in all five patients, with one operative complication involving a dissection of the common carotid at the access site, which was stented using the TCAR system. Postoperative DW-MRI did not identify any new intracerebral lesions in any patient following the procedure. No patient had a stroke, myocardial infarction, or death during hospitalization.

Conclusions

In this real-world, high-risk cohort, TCAR was completed with no evidence of new, postoperative DW-MRI lesions. These data further demonstrate that TCAR with flow reversal is an effective neuroprotective strategy for carotid revascularization. Further study is warranted to evaluate DW-MRI differences between TCAR and CEA.

Not a trifecta: complementary use of carotid artery revascularization techniques in the era of hybrid neurosurgery

OBJECTIVE

Carotid stenosis is currently treated by carotid endarterectomy (CEA), carotid artery stenting (CAS), or transcarotid artery revascularization (TCAR). This study sought to add to the literature by providing real-world data comparing the safety and effectiveness associated with the performance of these carotid revascularization techniques by dual-trained neurosurgeons.

METHODS

The authors performed a retrospective review of carotid stenosis databases at two US centers. Patients treated by CEA, transfemoral CAS, or TCAR for atherosclerotic carotid artery disease were included. Clinical outcomes were compared at 30 days after the procedure.

RESULTS

Seven hundred eighty patients were included (583 with CAS, 165 with CEA, and 32 with TCAR). Overall, 486 patients (62.3%) were men, and 393 (50.4%) had left-sided carotid stenosis. Most patients (n = 617, 79.1%) had symptomatic disease. Among the three treatment groups, there were no statistically significant differences with respect to 30-day ischemic events (CAS 3.8%, CEA 1.8%, TCAR 6.3%; p = 0.267) or 30-day mortality rates (CAS 3.6%, CEA 2.4%, TCAR 3.1%; p = 0.857). Male sex had significantly lower odds of 30-day transient ischemic attack (TIA) or stroke in both univariable (p = 0.024) and multivariable (p = 0.023) regression models. Increasing age had significantly higher odds of 30-day mortality on univariable (p = 0.006) and multivariable (p = 0.003) regression. Patients with the occurrence of 30-day TIA or stroke also had significantly higher odds of 30-day mortality on univariable (p < 0.001) and multivariable (p < 0.001) regression.

CONCLUSIONS

This real-world experience reflects the current practice of hybrid neurosurgery at two high-volume tertiary care centers and suggests that all three treatment modalities have comparable safety and effectiveness if patients are properly selected.

Evaluating postoperative outcomes in patients with hostile neck anatomy undergoing transcarotid artery revascularization versus transfemoral carotid artery stenting

BACKGROUND

Carotid endarterectomy is relatively contraindicated in patients with a hostile neck anatomy who were historically revascularized with transfemoral carotid artery stenting (TFCAS). As transcarotid artery revascularization (TCAR) has progressively replaced TFCAS, evidence pertaining to hostile neck anatomy and TCAR is necessary to establish its safety and feasibility in this subgroup of patients. Therefore, we analyzed the impact of a hostile neck anatomy on outcomes in patients undergoing TCAR and further compared them with those undergoing TFCAS to establish recommendations for standard of care.

METHODS

All patients undergoing TCAR and TFCAS from November 2016 to June 2021 in the Vascular Quality Initiative database were included. Patients were characterized into two groups based on the neck anatomy. Hostile neck anatomy was defined as a history of neck radiation or prior neck surgery including prior carotid endarterectomy or radical neck dissection. Primary outcomes included technical failure, access site complications (hematoma, stenosis, infection, pseudoaneurysm and arteriovenous fistula), and stroke or death. Secondary outcomes included stroke, transient ischemic attack (TIA), myocardial infarction (MI), death, and a composite end point of stroke or TIA. Patients with nonatherosclerotic or multiple lesions were excluded from the analysis. Primary analysis was performed with all patients undergoing TCAR and outcomes between patients with hostile and nonhostile neck anatomy were compared. Further analysis included a comparison of patients with a hostile neck anatomy undergoing TCAR and TFCAS. Univariable and multivariable logistic regression was used to assess impact of hostile neck anatomy on postoperative outcomes. Results were adjusted for relevant potential confounders including age, gender, race, degree of stenosis, symptomatic status, comorbidities, preoperative medications, anesthesia type, and protamine use.

RESULTS

Among the 19,859 patients who underwent TCAR during the study period, 3636 (18.3%) had a hostile neck anatomy. On univariate analysis, both groups had comparable outcomes except for higher rates of stroke or death in patients with hostile neck anatomy. After adjusting for potential confounders, there were no differences in technical failure (adjusted odds ratio [aOR], 1.14; 95% confidence interval [CI], 0.59-2.21; P = .699), stroke (aOR, 0.86; 95% CI, 0.58-1.28; P = .464), death (aOR, 0.82; 95% CI, 0.39-1.71; P = .598), and MI (aOR, 1.18; 95% CI, 0.71-1.97; P = .518). However, patients with hostile neck were at a 30% increased risk of access site complications (aOR, 1.30; 95% CI, 1.0-1.6; P = .023). Further adjusted analysis comparing the outcomes in TFCAS and TCAR among patients with hostile neck anatomy showed an almost four-fold increase in risk of death (aOR, 3.77; 95% CI, 1.49-9.53; P = .005) and technical failure (aOR, 3.69; 95% CI, 1.82-7.47; P < .001) among patients undergoing treatment with TFCAS.

CONCLUSIONS

Patients with a hostile neck anatomy undergoing TCAR experienced an increased risk of access site complications; however, the risk for technical failure and postoperative stroke/death, stroke, TIA, MI, or death was similar among both groups. TFCAS was associated with significant increase in the risk of death and technical failure compared with TCAR in this group of patients. These results confirm that TCAR should be the preferred minimally invasive revascularization procedure for patients with hostile neck anatomy.

Transcarotid Revascularization Timing and Early Postoperative Outcomes in Symptomatic Patients

Objective

Carotid endarterectomy (CEA) performed several days after onset of symptoms has been shown to be optimal in preventing procedure-related stroke. Transcarotid artery revascularization (TCAR) is an alternative hybrid procedure to treat high-risk for CEA patients. In this investigation, our aim is to determine the effect of timing of TCAR in symptomatic patients.

Methods

Procedures were captured prospectively at 2 independent health systems from 2016-2022 within a carotid intervention database. A retrospective analysis of this database was performed to generate cohorts by time to revascularization from onset of symptoms, with the short-interval revascularization (SIR) group defined as having a time to revascularization between 2-5 days; and long-interval revascularization (LIR) group having a time to revascularization of 6-180 days. Univariate analysis was performed comparing the cohorts at an α of .05.

Results

During the study period, 875 TCARs were captured, including 321 procedures performed in symptomatic patients. Of these, 84 had revascularization performed within 6 days after onset of symptoms (SIR) while 237 additional cases were completed 6 or more days after onset of symptoms (LIR). Baseline comorbidities were grossly similar between cohorts. Intraoperatively, SIR patients were less likely to develop bradycardia (4.8% vs 22.2%, P = .01) and experienced a shorter operative time (58 minutes vs 65 minutes, P = .02). Estimated blood loss, flow reversal time, radiation exposure, fluoroscopic time and contrast volume were identical between the groups. Length of stay in SIR patients was longer (1, IQR [1-3] vs 1, IQR [1-2] days, P < .01). Additionally, SIR patients seemed to trend toward a higher rate of reinterventions (3.6% vs .4%, P = .06). The incidence of ipsilateral or contralateral stroke, cranial nerve palsy, myocardial infarction, hematoma, stent thrombosis and death were statistically identical between the 2 groups.

Conclusion

Like the previous results established for CEA, symptomatic patients undergoing TCAR demonstrate similar outcomes if the procedure is performed 48 hours after the neurologic event.