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

Abstract

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.

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

“…Moreover, they found that TCAR is associated with a lower risk of MI (P = 0.004) and CNI (P < 0.00001) than CEA. 32 Wu and associates conducted another systematic review and meta-analysis. They included 12 studies and they also find no significant difference in the risks of stroke (OR = 1.07; 95% CI, 0.83-1.37), death (OR = 1.72; 95% CI, 0.82-3.62), stroke/death (OR = 1.05; 95% CI, 0.83-1.33) and stroke/death/MI (OR = 0.95; 95% CI, 0.78-1.16) between TCAR and CEA.…”

“…They found no statistical difference between TCAR and CEA in terms of stroke/death/MI (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). Moreover, they found that TCAR is associated with a lower risk of MI ( P =0.004) and CNI ( P <0.00001) than CEA 32 . Wu and associates conducted another systematic review and meta-analysis.…”

Update on Management of Symptomatic Carotid Stenosis

“…[22] TCAR has a similar prognosis to CEA and can be performed without running the risk of myocardial infarction. [29] Here, we reviewed the literature on carotid artery stenosis, CAS, CEA, TCAR, as well as emerging innovation to provide support when making clinical decisions for treatment. For lesser degrees of stenosis, CAS is often performed and CEA is only done if the need arises.…”

The intracranial effects of flow reversal during transcarotid artery revascularization

“…This preference is backed by its association with lower stroke and death rates and significantly fewer new lesions on diffusion-weighted magnetic resonance imaging (MRI) compared to CAS with distal protection, as demonstrated in recent studies. [ 6 , 7 ]…”

“…This preference is backed by its association with lower stroke and death rates and significantly fewer new lesions on diffusion-weighted magnetic resonance imaging (MRI) compared to CAS with distal protection, as demonstrated in recent studies. [6,7] Despite being an innovative and minimally invasive procedure, the cerebrovascular flow dynamics during TCAR procedures have not been thoroughly elucidated. The "flow reversal" concept is better understood by examining alterations in intracranial circulation and embolic events using transcranial Doppler (TCD).…”