Direct Transcervical Access vs the Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta-Analysis

Embolic protection devices for carotid artery stenting: A network meta-analysis

OBJECTIVES

Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications.

METHODS

A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS

Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups.

CONCLUSIONS

PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.

The Efficacy of Transcarotid Artery Revascularization With Flow Reversal System Compared to Carotid Endarterectomy: A Systematic Review and Meta-Analysis

Background: Carotid artery stenosis has long been a critical cause of stroke and death, and it can seriously affect the life quality. Transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA) are both feasible therapies for this disease. This systematic review and meta-analysis aim to evaluate if the efficacy of the two approaches is comparable.

Methods: Clinical studies up to March 2021 were searched through PubMed, Embase, and Scopus from a computer. The screening process was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Newcastle-Ottawa Scale (NOS) was used for methodological quality assessment of works of literature meeting the inclusion criteria, and Review Manager 5.4 was used for data synthesis. The I² statistic was performed to measure the heterogeneity, and M-H/I-V fixed or random model was utilized depending on the I² value. The evidence evaluation was accomplished based on grades of recommendation, assessment, development, and evaluation (GRADE) online tool.

Results: A total of 14,200 subjects (six comparative studies) were finally included in this pooled study. There is no statistical discrepancy between the two treatments on reducing stroke/death/myocardial infarction (odds ratio [OR] 0.85, 95% CI 0.67–1.07), stroke (OR 1.03, 95% CI 0.77–1.37), or death (OR 1.14, 95% CI 0.67–1.94). Besides, TCAR is associated with a lower incidence of myocardial infarction (P = 0.004), cranial nerve injury (P < 0.00001), and shorter procedure time (P < 0.00001) than CEA among the overall cohort.

Conclusions: TCAR is a rapidly developing treatment that reaches a comparable prognosis to CEA and significantly reduces the risk of myocardial infarction under the well-matched condition, which is a dependable choice for patients with carotid stenosis.

Transcervical Versus Transfemoral Approach in Carotid Stenting Real World Experience in a Community Hospital

INTRODUCTION

Peri-procedural embolic events are the Achilles' heel of carotid stenting. To overcome this complication, transcervical access to the carotid artery was introduced. In this study we describe our "our life" experience with the transcervical approach in a community hospital.

MATERIAL AND METHODS

All carotid stent procedures between January 2010 and December 2020 were included in this retrospective analysis. The transcervical approach was compared to the transfemoral approach. In both procedures open-cell, closed-cell design and hybrid stents were used. In-hospital stroke was the primary outcome measure.

RESULTS

A total of 340 procedures were performed, in 184 patients the transfemoral approach was used and in 156 patients the transcervical approach was used. In 12 patients (3.5%) an in-hospital stroke was diagnosed, 4 in the transfemoral group (2.2%) and 8 in the transcervical group (5.1%) (P = 0.14). In the multivariate analyses a symptomatic lesion was associated with in-hospital stroke. Neither type of access nor cell design was associated with increased risk of in-hospital stroke.

CONCLUSIONS

In contrast to previous studies, we could not confirm the advantages of the transcervical approach. However, conclusions should be carefully drawn, since this study is retrospective and was performed with multiple surgeon and different kind of stents.

Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy

BACKGROUND AND PURPOSE

Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke. The optimal procedural modality for this indication has yet to be determined. Here, we evaluate the in-hospital outcomes of transcarotid artery revascularization (TCAR), redo-CEA, and transfemoral carotid artery stenting (TFCAS) in a large contemporary cohort of patients who underwent treatment for restenosis after CEA.

METHODS

We performed a retrospective analysis of all patients in the vascular quality initiative database who underwent TCAR, redo-CEA, or TFCAS after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral CAS were excluded from this analysis. In-hospital outcomes following TCAR versus CEA and TCAR versus TFCAS were evaluated using multivariate logistic regression analysis.

RESULTS

A total of 4425 patients were available for this analysis. There were 963 (21.8%) redo-CEA, 1786 (40.4%) TFCAS, and 1676 (37.9%) TCAR. TCAR was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% CI, 0.24-0.70], P=0.021), stroke (OR, 0.46 [95% CI, 0.23-0.93], P=0.03), myocardial infarction (MI; OR, 0.32 [95% CI, 0.14-0.73], P=0.007), stroke/transient ischemic attack (OR, 0.42 [95% CI, 0.24-0.74], P=0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24-0.70], P=0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the 2 groups (OR, 0.99 [95% CI, 0.28-3.5], P=0.995). TCAR was also associated with lower odds of stroke/transient ischemic attack (OR, 0.37 [95% CI, 0.18-0.74], P=0.005) when compared with TFCAS. There was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI between TCAR and TFCAS.

CONCLUSIONS

TCAR was associated with significantly lower odds of in-hospital stroke, MI, stroke/transient ischemic attack, stroke/death, and stroke/death/MI when compared with redo-CEA and lower odds of in-hospital stroke/transient ischemic attack when compared with TFCAS. Additional long-term studies are warranted to establish the role of TCAR for the treatment of restenosis after CEA.

Comparison of Transradial vs Transfemoral Access in Neurovascular Fellowship Training: Overcoming the Learning Curve

BACKGROUND

The transradial access (TRA) is rapidly gaining popularity for neuroendovascular procedures as there is strong evidence for its benefits compared to the traditional transfemoral access (TFA). However, the transition to TRA bears some challenges including optimization of the interventional suite set-up and workflow as well as its impact on fellowship training.

OBJECTIVE

To compare the learning curves of TFA and TRA for diagnostic cerebral angiograms in neuroendovascular fellowship training.

METHODS

We prospectively collected diagnostic angiogram procedural data on the performance of 2 neuroendovascular fellows with no prior endovascular experience who trained at our institution from July 2018 until June 2019. Metrics for operator proficiency were minutes of fluoroscopy time, procedure time, and volume of contrast used.

RESULTS

A total of 293 diagnostic angiograms were included in the analysis. Of those, 57.7% were TRA and 42.3% were TFA. The median contrast dose was 60 cc, and the median radiation dose was 14 000 μGy. The overall complication rate was 1.4% consisting of 2 groin hematomas, 1 wrist hematoma, and 1 access-site infection using TFA. The crossover rate to TFA was 2.1%. Proficiency was achieved after 60 femoral and 95 radial cases based on fluoroscopy time, 52 femoral and 77 radial cases based on procedure time, and 53 femoral and 64 radial cases based on contrast volume.

CONCLUSION

Our study demonstrates that the use of TRA can be safely incorporated into neuroendovascular training without causing an increase in complications or significantly prolonging procedure time or contrast use.

Transcervical carotid artery revascularization: A systematic review and meta-analysis of outcomes

OBJECTIVE

Carotid artery stenosis is considered a determinant factor for cerebrovascular events, estimated to be the cause of 10% to 20% of all ischemic strokes. Transcervical carotid artery revascularization (TCAR) has been offered as an alternative to transfemoral carotid artery stenting and carotid endarterectomy to treat carotid artery stenosis.

METHODS

We performed a systematic review and meta-analysis of prospective and retrospective studies reporting the outcomes of patients who had undergone TCAR for carotid artery stenosis. The incidence of periprocedural adverse events was calculated.

RESULTS

A total of 45 studies with 14,588 patients met the predefined eligibility criteria and were included in the present meta-analysis. The technical success rate was 99% (95% confidence interval [CI], 98%-99%). The reasons for technical failure included an inability to cross the lesion and/or failure to deploy the stent. Access site complications occurred in 2% of all cases (95% CI, 1%-2%; 30 studies). Overall, the incidence of cranial nerve (CN) injuries was very rare, with only 33 of 8994 patients experiencing neurologic deficits attributed to CN involvement. Bleeding complications were reported by 20 studies and occurred in 2% (95% CI, 1%-3%) of all cases. The overall periprocedural all-cause mortality and stroke rate was 0.5% and 1.3%, respectively. In-stent restenosis was observed in 4 of 260 patients (1.5%; 7 studies), and early (30-day) reocclusion or acute thrombosis of the target lesion occurred in 12 of 1243 patients (∼1%; 11 studies).

CONCLUSIONS

The results from the present study have provided significant evidence that TCAR is a very promising and safe carotid revascularization approach with favorable technical success rates associated with low periprocedural stroke and CN injury rates.

Editor's Choice - Early and Late Outcomes after Transcarotid Revascularisation for Internal Carotid Artery Stenosis: A Systematic Review and Meta-Analysis

OBJECTIVE

Transcarotid/transcervical revascularisation (TCAR) is an alternative to carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS). This review aimed to evaluate pooled data on patients undergoing TCAR.

DATA SOURCES

Medline, Embase, Scopus, and Cochrane Library databases were used.

REVIEW METHODS

This systematic review was conducted under Systematic Reviews and Meta-Analysis guidelines. Eligible studies (published online up to September 2020) reported 30 day mortality and stroke/transient ischaemic attack (TIA) rates in patients undergoing TCAR. Data were pooled in a random effects model and weight of effect for each study was also reported. Quality of studies was evaluated according to Newcastle - Ottawa scale.

RESULTS

Eighteen studies (three low, seven medium, and eight high quality) included 4 852 patients (4 867 TCAR procedures). The pooled 30 day mortality rate was 0.7% (n = 32) (95% confidence interval [CI] 0.5 - 1.0), 30 day stroke rate 1.4% (n = 62) (95% CI 1.0 - 1.7), and 30 day stroke/TIA rate 2.0% (n = 92) (95% CI 1.4 - 2.7). Pooled technical success was 97.6% (95% CI 95.9 - 98.8). The cranial nerve injury rate was 1.2% (95% CI 0.7 - 1.9) (n = 14; data from 10 studies) while the early myocardial infarction (MI) rate was 0.4% (95% CI 0.2 - 0.6) (n = 16; data from 17 studies). The haematoma/bleeding rate was 3.4% (95% CI 1.7 - 5.8) (n = 135; data from 10 studies), with one third of these cases needing drainage or intervention. Within a follow up of 3 - 40 months the restenosis rate was 4% (95% CI 0.1 - 13.1) (data from nine studies; n = 64/530 patients) and death/stroke rate 4.5% (95% CI 1.8 - 8.4) (data from five studies; n = 184/3 742 patients). Symptomatic patients had a higher risk of early stroke/TIA than asymptomatic patients (2.5% vs. 1.2%; odds ratio 1.99; 95% CI 1.01 - 3.92); p = .046; data from eight studies).

CONCLUSION

TCAR is associated with promising early and late outcomes, with symptomatic patients having a higher risk of early cerebrovascular events. More prospective comparative studies are needed in order to verify TCAR as an established alternative treatment technique.

Primary mechanism of stroke reduction in transcarotid artery revascularization is dynamic flow reversal

OBJECTIVE

Recent studies have suggested that the low risk of stroke and death associated with transcarotid artery revascularization (TCAR) is partially attributable to a robust dynamic flow reversal system and the avoidance of the atherosclerotic aortic arch during stenting. However, the benefits of flow reversal compared with distal embolic protection (DEP) in reducing stroke or death in TCAR have not been studied.

METHODS

All patients undergoing carotid artery stenting (CAS) via the transcarotid route with either dynamic flow reversal (TCAR) or DEP (TCAS-DEP) in the Vascular Quality Initiative from September 2016 to November 2019 were analyzed. Both multivariable logistic regression and nearest neighbor propensity score-matched analysis were performed to explore the differences in outcomes between the two procedures. The primary outcome was in-hospital stroke or death. The secondary outcomes were stroke, death, myocardial infarction (MI), and the composite of stroke, death, and MI. A secondary analysis was performed to compare transcarotid stenting with DEP vs transfemoral CAS with DEP to evaluate the effects of crossing the aortic arch.

RESULTS

A total of 8426 patients were identified (TCAS-DEP, n = 287; 3.4%). TCAR was associated with a lower risk of in-hospital stroke or death (1.6% vs 5.2%; odds ratio [OR], 0.35; 95% confidence interval [CI], 0.20-0.64; P = .001), stroke (1.4% vs 4.2%; OR, 0.37; 95% CI, 0.20-0.68; P = .002), and stroke/death/MI (2.0% vs 5.2%; OR, 0.41; 95% CI, 0.23-0.71; P = .001) compared with TCAS-DEP. Among the 274 pairs of patients identified with propensity score matching, TCAR was associated with a lower risk of stroke/death (1.1% vs 4.7%; risk ratio [RR], 0.23; 95% CI, 0.06-0.81; P = .021) and stroke (0.4% vs 4.0%; RR, 0.09; 95% CI, 0.01-0.70; P = .006) compared with TCAS-DEP but no differences in stroke/death/MI (1.8% vs 4.7%; RR, 0.38; 95% CI, 0.15-1.02; P = .077). The secondary analysis found no differences in stroke between TCAS-DEP and transfemoral CAS with DEP (4.9% vs 3.7%; RR, 1.3; 95% CI, 0.36-1.63; P = .65).

CONCLUSIONS

Compared with TCAS-DEP, TCAR was associated with a lower risk of perioperative stroke or death and stroke. This finding implies that dynamic flow reversal might provide better neuroprotection than does a distal embolic filter in reducing the perioperative risk of stroke. Avoiding the aortic arch did not confer any reduction in the stroke rate. The present findings serve to separate the clinical benefit of dynamic flow reversal from that of avoiding the aortic arch during TCAR.

Intravascular Lithotripsy for Treatment of Calcified Lesions During Carotid Artery Stenting

Purpose:

To report the use of intravascular lithotripsy (IVL) in the treatment of calcified carotid artery lesions.

Materials and Methods:

The records of 21 high-surgical-risk patients (mean age 75.1±8.1 years; 17 men) who were treated at 8 centers for carotid artery stenosis ≥70% were retrospectively reviewed. Twelve patients had a history of cerebrovascular disease. All patients had heavily calcified carotid artery lesions: 19 de novo and 2 in-stent restenoses (ISR). The mean baseline stenosis was 82.3%±9.7%. IVL was utilized at the discretion of the operator, followed by balloon angioplasty. Embolic protection devices were used in all cases.

Results:

In 19 patients, IVL was followed by stent implantation; the 2 ISR lesions were dilated only. The mean IVL balloon diameter was 4.64±1.13 mm, and the mean number of IVL pulses applied was 67.2±61.4 (range 10–180). All procedures were technically successful (<30% residual stenosis). No patients developed symptomatic bradycardia or hypotension due to IVL, and there were no adverse events associated with IVL delivery. All patients were discharged on dual antiplatelet therapy. Seventeen days after the procedure, 1 patient experienced an ischemic stroke that was deemed due to aortic arch manipulation during transfemoral access. Carotid duplex ultrasound examination identified significant restenosis (>70%) in 1 asymptomatic patient at 12 months after the index procedure. No patients required reintervention during a median follow-up of 6 months (range 1–12).

Conclusion:

This preliminary experience demonstrates that IVL can be a safe and effective approach for the management of severely calcified carotid lesions. Further research is warranted to determine the longer-term safety and efficacy of IVL for dilation of calcified carotid artery lesions as an adjunct to carotid artery stenting.

Synchronous versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid artery stenosis: A systematic review and meta-analysis

BACKGROUND

Coronary artery disease requiring coronary artery bypass graft (CABG) frequently coexists with critical carotid stenosis. The most optimized strategy for treating concomitant carotid and coronary artery disease remains debatable.

OBJECTIVE

The aim of this meta-analysis was to compare synchronous CAS and CABG versus staged CAS and CABG for patients with concomitant coronary artery disease and carotid artery stenosis in terms of peri-operative (30-day) and long-term clinical outcomes.

METHODS

This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane database until December 2019. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess heterogeneity.

RESULTS

Four studies comprising 357 patients were included in this meta-analysis. Patients who were treated with the synchronous approach had a statistically significant higher risk for peri-operative stoke (OR: 3.71; 95% CI: 1.00-13.69; I² = 0%) compared tο the staged group. Peri-operative mortality (OR: 4.50; 95% CI: 0.88-23.01; I² = 0%), myocardial infarction (MI) (OR: 1.54; 95% CI: 0.18- 13.09; I² = 0%), postoperative bleeding (OR: 0.27;95% CI: 0.02-3.12; I² = 0%), transient ischemic attacks (TIA) (OR: 0.60; 95% CI: 0.04- 9.20; I² = 0.0%), acute kidney injury (AKI) (OR: 0.34; 95% CI: 0.03-4.03; I² = 0.0%) and atrial fibrillation rates (OR:0.27; 95% CI: 0.02-3.12; I² = 0.0%) were similar between the two groups. Synchronous CAS-CABG and staged CAS followed by CABG were associated with similar rates of late mortality (OR: 3.75; 95% CI: 0.50-27.94; I² = 0.0%), MI (OR: 0.33; 95% CI: 0.01-12.03; I² = 0.0%) and stroke (OR:3.58; 95% CI:0.84-15.20; I² = 0.0%) after a mean follow-up of 47 months.

CONCLUSION

The simultaneous approach was associated with an increased risk of 30-day stroke compared to staged CAS and CABG. However, no statistically significant difference was found in long-term results of mortality, MI and stroke between the two approaches. Future studies are warranted to validate our results.

A Systematic Review and Meta-Analysis of Transcarotid Artery Revascularization with Dynamic Flow Reversal Versus Transfemoral Carotid Artery Stenting and Carotid Endarterectomy

BACKGROUND

Transfemoral carotid artery stenting (TFCAS) was introduced as a less invasive option for carotid revascularization in patients at high risk for complications from carotid endarterectomy (CEA). The increased perioperative stroke and death risk of TFCAS has however prevented TFCAS from widespread acceptance as an alternative to CEA in high-risk patients. Recent research suggests that transcarotid artery revascularization (TCAR) may be associated with a low stroke and death risk and potentially meet the needs of patients at high surgical risk. We aimed to estimate the 30-day risk of stroke or death of TCAR and compare it to TFCAS and CEA.

METHODS

We searched PubMed, Cochrane, Embase, and Scopus for studies of patients treated with TCAR. Meta-analysis was conducted when appropriate. A logistic-normal random-effects model with logit transformation was used to estimate the pooled event rates after TCAR. Pooled Mantel-Haenszel odds ratios (ORs) of events comparing TCAR to TFCAS and CEA were calculated using a fixed-effects model. Heterogeneity among studies was quantified with the chi-squared statistic of the likelihood ratio (LR) test that compares the random-effects and fixed-effects models.

RESULTS

Nine nonrandomized studies evaluating 4012 patients who underwent TCAR were included. The overall 30-day risks after TCAR were stroke/death, 1.89% (95% confidence interval [CI]: 1.50, 2.37); stroke, 1.34% (95% CI: 1.02,1.75); death, 0.76% (95% CI: 0.56, 1.08); myocardial infarction (MI), 0.60% (95% CI: 0.23, 1.59); stroke/death/MI, 2.20% (95% CI: 1.31, 3.69); cranial nerve injury (CNI), 0.31% (95% CI: 0.12, 0.83). The failure rate of TCAR was 1.27% (95% CI: 0.32, 4.92). Two nonrandomized studies suggested that TCAR was associated with lower risk of stroke and death as compared with TFCAS (1.33% vs. 2.55%, OR: 0.52, 95% CI: 0.36, 0.74 and 0.76% vs. 1.46%, OR: 0.52, 95% CI: 0.32, 0.84, respectively). Four nonrandomized studies suggested that TCAR was associated with a lower risk of CNI (0.54% and 1.84%, OR: 0.52, 95% CI: 0.36, 0.74) than CEA, but no statistically significant difference in the 30-day risk of stroke, stroke/death, or stroke/death/MI.

CONCLUSIONS

Among patients undergoing TCAR with dynamic flow reversal for carotid stenosis the 30-day risk of stroke or death was low. The perioperative stroke/death rate of TCAR was similar to that of CEA while CNI risk was lower. Larger prospective studies are needed to account for confounding factors and provide higher certainty.

An updated systematic review and meta-analysis of results of transcervical carotid artery stenting with flow reversal

OBJECTIVE

Transcervical carotid artery stenting (CAS) has emerged as an alternative to transfemoral CAS. An earlier systematic review from our group (n = 12 studies; 739 transcervical CAS procedures [489/739 with flow reversal]) demonstrated that transcervical CAS is a safe procedure associated with a low incidence of stroke and complications. Since then, new studies have been published adding nearly 1600 patients to the literature. We aimed to update our early systematic review and also to perform a meta-analysis to investigate outcomes specifically after transcervical CAS with flow reversal.

METHODS

An electronic search of PubMed/MEDLINE, Embase, and the Cochrane databases was carried out to identify studies reporting outcomes after transcervical CAS with flow reversal. Crude event rates for outcomes of interest were estimated by simple pooling of data. A proportion meta-analysis was also performed to estimate pooled outcome rates.

RESULTS

A total of 18 studies (n = 2110 transcervical CAS procedures with flow reversal) were identified. A high technical success (98.25%) and a low mortality rate (0.48%) were recorded. The crude rates of major stroke, minor stroke, transient ischemic attack, and myocardial infarction (MI) were 0.71%, 0.90%, 0.57%, and 0.57%, respectively; a cranial nerve injury occurred in 0.28% of the procedures. A neck hematoma was reported in 1.04% of the procedures, and a carotid artery dissection occurred in 0.76% of the interventions; in 1.09% of the cases, conversion to carotid endarterectomy was required. After a meta-analysis was undertaken, the pooled technical success rate was 98.69% (95% confidence interval [CI], 97.19-99.70). A pooled mortality rate of 0.04% (95% CI, 0.00-0.29) was recorded. The pooled rate of any type of neurologic complications was 1.88 (95% CI, 1.24-2.61), whereas the pooled rates of major stroke, minor stroke, and transient ischemic attack were 0.12% (95% CI, 0.00-0.46), 0.15% (95% CI, 0.00-0.50), and 0.01% (95% CI, 0.00-0.22), respectively. The pooled rate of bradycardia/hypotension was 10.21% (95% CI, 3.99-18.51), whereas the pooled rate of MI was 0.08% (95% CI, 0.00-0.39). A neck hematoma after transcervical CAS was recorded in 1.51% (95% CI, 0.22-3.54) of the procedures; in 0.74% (95% CI, 0.05-1.95) of the interventions, conversion to CEA was required. Finally, a carotid artery dissection during transcervical CAS occurred in 0.47% (95% CI, 0.00-1.38) of the procedures.

CONCLUSIONS

This updated systematic review and meta-analysis demonstrated that transcervical CAS with flow reversal is associated with high technical success, almost zero mortality, and low rates of major stroke, minor stroke, MI, and complications.

Carotid Artery Stenting in Asymptomatic Carotid Artery Stenosis: JACC Review Topic of the Week

The advance of therapies to reduce the stroke impact of asymptomatic carotid artery stenosis has proved difficult over the last decade. Disagreement concerning the underlying randomized control trials has limited entry into the care arena of endovascular therapies. Recently, advances in percutaneous therapies for carotid artery disease have been reported and provide a substantial database supporting the further incorporation of endovascular-based therapies in patients who need revascularization and meet selection criteria. With a second randomized control trial now published, it is time for a re-evaluation of endovascular therapy as a component of carotid artery care. This review describes the advances in the field in the last 5 years, clarifying the current position of these therapies in the care of the patient with asymptomatic carotid artery disease.