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

Abstract

WHAT THIS PAPER ADDSThis systematic review summarises the evidence for transcarotid revascularisation (TCAR) in patients with internal carotid artery stenosis. This technique offers an alternative strategy in patients where carotid endarterectomy (CEA) or transfemoral stenting face difficulties. This review evaluates early and late outcomes of the method in contrast to other similar reviews. Data indicate that TCAR is safe and efficient although symptomatic patients still carry a higher risk of early cerebrovascular complications. Prospectively designed studies comparing outcomes between TCAR and CEA in symptomatic patients are needed to further evaluate the benefit of this technique.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 e 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 ¼ 32) (95% confidence interval [CI] 0.5 e 1.0), 30 day stroke rate 1.4% (n ¼ 62) (95% CI 1.0 e 1.7), and 30 day stroke/TIA rate 2.0% (n ¼ 92) (95% CI 1.4 e 2.7). Pooled technical success was 97.6% (95% CI 95.9 e 98.8). The cranial nerve injury rate was 1.2% (95% CI 0.7 e 1.9) (n ¼ 14; data from 10 studies) while the early myocardial infarction (MI) rate was 0.4% (95% CI 0.2 e 0.6) (n ¼ 16; data from 17 studies). The haematoma/bleeding rate was 3.4% (95% CI 1.7 e 5.8) (n ¼ 135; data from 10 studies), with one third of these cases needing drainage or intervention. Within a follow up of 3 e 40 months the restenosis rate was 4% (95% CI 0.1 e 13.1) (data from nine studies; n ¼ 64/530 patients) and death/stroke rate 4.5% (95% CI 1.8 e 8.4) (data from five studies; n ¼ 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 e 3.92); p ¼ .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.

Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis

“…SGS comparisons against contemporary carotid endarterectomy that shows a 30-day DSM of ≈1.9% [ 233 ] is particularly needed. Very relevant in the context of the present analysis are the TCAR data, demonstrating that despite optimized intraprocedural cerebral protection, the use of FGS in TCAR is associated with a two-fold increase in early stroke/TIA in symptomatic vs. asymptomatic patients (2.5% vs. 1.2%, odds ratio 1.99, 95% CI 1.01–3.92, p = 0.046) [ 234 ]. This suggests that SGS plaque sealing might improve TCAR outcomes in symptomatic patients and high-risk lesions in particular [ 235 ].…”

Comparison of Recent Practice Guidelines for the Management of Patients With Asymptomatic Carotid Stenosis

“…Recent pooled data indicate that in asymptomatic patients the results for TCAR are better than in symptomatic patients. 28 The emerging role and the possible potential of TCAR for the treatment of carotid patients was recognized in the most recent guidelines, the 2021 ESO 10 and 2021 SVS 11 guidelines. However, both guidelines admitted that it is premature to make any solid recommendations at this stage.…”

Carotid Artery Stenting Using the Walrus Balloon Guide Catheter With Flow Reversal for Proximal Embolic Protection: Technical Description and Single-Center Case Series

“…5 Although this system has not been compared with CAS or CEA in randomized trials, observational and prospective matched studies report comparable safety. 20 The TCAR procedure obviates unprotected traversal of the aortic arch, which can be beneficial in patients with severe aortic atherosclerosis or challenging arch anatomy. However, the duration for TCAR may be longer than that for CAS because it requires skin incision and dissection and is performed under general anesthesia at most centers.…”