Seven years of the transcarotid artery revascularization surveillance project, comparison to transfemoral stenting and endarterectomy

Outcomes of redo vs primary carotid endarterectomy in the transcarotid artery revascularization era

OBJECTIVE

Outcomes following redo carotid endarterectomy (rCEA) have been shown to be worse than those after primary CEA (pCEA). Additional research has shown that outcomes are better with transcarotid artery revascularization (TCAR) for restenosis after CEA compared with rCEA and transfemoral carotid artery stenting; however, not all patients are eligible for TCAR or transfemoral carotid artery stenting. Given the increasing utilization of endovascular techniques, this study aims to evaluate changes in outcomes of rCEA vs pCEA before and after the approval of TCAR by the United States Food and Drug Administration in 2015.

METHODS

All patients between 2003 and 2023 who underwent CEA in the Vascular Quality Initiative were included and categorized as pCEA or rCEA. Cochrane-Armitage trend testing was used to examine trends in proportion of rCEA compared with pCEA, and the Mann-Kendall trend test was used for perioperative outcomes following rCEA overtime. Multivariable logistic regression was used to compare in-hospital stroke/death, stroke, death, and stroke/death/myocardial infarction following rCEA vs pCEA after stratifying patients into two cohorts: 2003 to 2015 and 2016 to 2023 (before and after introduction of TCAR). Analysis was also performed based on preoperative symptoms.

RESULTS

Of 198,150 patients undergoing CEA, 98.4% were pCEA and 1.6% were rCEA. During the study period, the proportion of rCEA in the Vascular Quality Initiative decreased from 2.3% to 1.0% as endovascular methods became more available (P < .001). Trend testing of individual outcomes showed an increase in the stroke/death rate following rCEA over time (P = .019) despite an improvement in the death rate (P = .009). From 2003 to 2015, patients undergoing rCEA had higher odds of stroke/death compared with pCEA (2.4% vs 1.2%; adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.14-2.73; P = .007). Higher stroke/death rates after rCEA persisted only in asymptomatic patients (2.3% vs 1.1%; aOR, 2.03; 95% CI, 1.19-3.25; P = .006); however, there was no difference in symptomatic patients (3.0% vs 2.0%; aOR, 1.37; 95% CI, 0.51;3.01; P = .50). In the late period, rCEA had higher odds of stroke/death compared with pCEA (3.1% vs 1.3%; aOR, 2.45; 95% CI, 1.85-3.18; P < .001), and the association was seen in asymptomatic patients (1.9% vs 1.0%; aOR, 1.95; 95% CI, 1.29-2.82; P < .001) and symptomatic patients (6.3% vs 2.0%; aOR, 3.23; 95% CI, 2.17-4.64; P < .001).

CONCLUSIONS

The proportion of rCEAs done yearly in the United States has been decreasing as endovascular options became available. As the rate of rCEA has decreased, outcomes have been worsening, with an increasing stroke/death rate seen over time, driven primarily by worse outcomes in symptomatic patients. Stroke/death rates for asymptomatic patients fall within Society for Vascular Surgery guidelines, and so the choice between rCEA, CAS, or medical management should be made after shared decision-making between a patient and their surgeon. However, with an in-hospital stroke death rate of over 6% symptomatic patients should be selected very carefully, as some are less likely to benefit from rCEA.

FullBlock-Assisted Percutaneous Carotid Artery Revascularization: A Novel Approach for Enhanced Neuroprotection

This report describes a first-in-human case of percutaneous carotid artery revascularization (PCAR) using FullBlock, a neuroprotective system that consists of a dual-occlusion balloon and reverse-flow neuroprotective system. The patient was a 77-year-old woman with severe left internal carotid artery stenosis and multiple cardiovascular comorbidities. She was deemed unsuitable for carotid endarterectomy. PCAR with stenting was performed successfully with general anesthesia. Neuroprotection depended on controllable reverse hemodynamics established with the femoral vein and communicating intracranial arteries. Atherosclerotic plaques were filtered in the extra-anatomic reverse flow tube. One-month follow-up was favorable. This case demonstrates the feasibility of FullBlock-assisted PCAR with stenting as a promising alternative for high-risk patients. Transradial and femoral access can be avoided, adding potential benefits of reduced operative complexity and enhanced neuroprotection.

Outcomes and Insights from a Decade of Transcarotid Artery Revascularization in Community Practice

OBJECTIVE

Transcarotid arterial revascularization (TCAR) with flow reversal is a well-established minimally invasive alternative to carotid endarterectomy. Our multicenter, private practice is an early adopter and has performed TCARs in the community since 2013. We report our real-world experience after performing 650 TCARs over ten years in the community.

METHODS

655 TCAR procedures were performed on 588 patients between 2013-2024. A retrospective chart review was performed on these procedures. The cohort included nine vascular surgeons across ten hospitals. All procedures used the enroute transcarotid neuroprotection system (NPS), which uses common carotid access and high-rate flow reversal as embolic protection during stenting. The primary endpoints for this study are 30-day rates of stroke and myocardial infarction (MI). Secondary endpoints included operative time, cranial nerve injury, neck hematoma requiring evacuation, arterial dissection, and death.

RESULTS

655 TCAR procedures were performed on 588 unique patients. 403 (61.52%) of patients were asymptomatic at the time of surgery. The median patient age was 73 (67-79) years. Patient medical history, surgical history, pre- and post-dilation balloon sizes, stent sizes, operative time, flow-reversal time, contrast volume, reoperation status, discharge statin, and anticoagulation therapies are listed and summarized in the tables below. Eleven patients suffered a perioperative stroke (1.68%) within 30 days of the operations, and ten (1.53%) suffered a stroke after thirty days but within one year of the operation. MI occurred in one patient (0.15%) within 30 days and six (0.91%) within one year. Cranial nerve injury occurred in 10 (1.52%) patients, defined as either dysphagia (n=1) or hoarseness (n=9). Neck hematoma with evacuation occurred in 10 patients (1.53%). An arterial dissection transpired in a single patient (0.15%).

CONCLUSIONS

Over the last decade, TCAR has emerged as an effective and efficient first-line therapy for treating suitable patients with carotid artery stenosis regularly in less than 1 hour of operative time. Early adoption and integration of this technology into practice have yielded excellent patient outcomes, matching or surpassing those reported in the literature for the gold standard, CEA.

Retroperitoneal vs transperitoneal approach for nonruptured open conversion after endovascular aneurysm repair

OBJECTIVE

Several studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach for abdominal aortic aneurysm (AAA) repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after endovascular aneurysm repair (EVAR).

METHODS

We included all patients who underwent open conversion after EVAR between 2010 and 2022 in the Vascular Quality Initiative. Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. The 5-year mortality was evaluated using Kaplan-Meier and Cox regression.

RESULTS

We identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 years [interquartile range, 70-79 years] vs 73.5 years [interquartile range, 68-79 years]; P < .001), and more frequently had prior myocardial infarction (33% vs 22%; P = .002). Compared with the TP approach, the RP approach was used less frequently in cases of associated iliac aneurysm (19% vs 27%; P = .026), but more frequently with associated renal bypass (7.8% vs 1.7%; P < .001) and by high-volume physicians (highest quintile, >7 AAA annually: 41% vs 17%; P < .001) and in high-volume centers (highest quintile, >35 AAA annually: 36% vs 20%; P < .001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs 21%; P < .001), and an infrarenal clamp (25% vs 36%; P < .001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs TP: 3.8% vs 7.5%; P = .077). After risk adjustment, RP patients had similar odds of perioperative mortality (adjusted odds ratio [aOR], 0.49; 95% confidence interval [CI], 0.22-1.10; P = .082), and lower odds of intestinal ischemia (aOR, 0.26; 95% CI, 0.08-0.86; P = .028) and in-hospital reintervention (aOR, 0.43; 95% CI, 0.22-0.85; P = .015). No significant differences were found in the other perioperative complications or 5-year mortality (aHR, 0.79; 95% CI, 0.47-1.32; P = .37).

CONCLUSIONS

Our findings suggest that the RP approach may be associated with a lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.