Transcarotid artery revascularization (TCAR): a technical video

Objective Current carotid artery stenting practice guidelines recommend dual antiplatelets to reduce major adverse cardiovascular events during and after transcarotid revascularization (TCAR). However, some patients are poor candidates for this regimen, due to preexisting need for anticoagulation, allergies, and/or risk of major bleeding. Therefore, this investigation was performed to review outcomes associated with patients undergoing TCAR while on alternative medication regimens to determine safety and efficacy. Methods A retrospective review was performed of a combined database created by the combination of institutional carotid revascularization archives maintained at 2 high-volume TCAR health systems. Patients taking dual antiplatelets were compared to those on nontraditional medications with respect to demographics and perioperative and long-term outcomes. Results Between our 2 member institutions, 729 TCAR procedures, consisting of 549 patients on dual antiplatelets and 180 on alternative treatments, qualified for study inclusion and analyzed. The cohort not taking dual antiplatelets presented with a heavier comorbidity burden by Charlson Comorbidity Index (5.3 ± 2.2 vs 6.1 ± 2.2, P < .01). Additionally, these patients underwent higher risk revascularization procedures, as they had a higher proportion of symptomatic lesions (34.6% vs 43.0%, P = .03). Despite these deviations in baseline characteristics, similar outcomes between groups were observed in the 30-day perioperative period with respect to stroke (2.2% vs 2.8%, P = .58), death (1.3% vs 1.1%, P > .99), and myocardial infarction (.4% vs 0%, P > .99). Similarly, rates of reintervention (1.6% vs 1.1%, P > .99), hematoma formation (2.4% vs 2.2%, P > .99), and stent thrombosis (.5% vs .6%, P > .99) were consistent, regardless of antiplatelet status. At follow-up of 25.4 and 29.1 months, respectively, for the dual antiplatelet and alternative treatment cohorts, no deviations with respect to reintervention, stroke, myocardial infarction, or stent thrombosis were noted. However, there was an increased risk of death (5.4% vs 13.5%, P = .02) in the alternative regimen group. Conclusion In this small series of TCARs, patients not maintained on dual antiplatelets did not experience more perioperative adverse events after TCAR. However, more studies, in larger series, are required to verify and validate these findings.

Section: Introductionmentioning

confidence: 99%

Safety of Transcarotid Revascularization in Patients with a Contraindication to Dual Antiplatelets

Olvera

Tanaka

Madison

et al. 2022

“…3 Transcarotid artery revascularization (TCAR) with the "Enroute neuroprotection device" is a hybrid carotid stenting technique commercialized by Silk Road Medical (Sunnyvale, CA), and approved for commercial use in 2015, in which embolic neuroprotection is achieved via cerebral flow reversal. 4,5 To accomplish this, sheaths are placed in the common carotid artery and the femoral vein and connected. 5 Next, the common carotid is clamped proximal to the arterial sheath, allowing the flow to reverse into an external circuit connected to the femoral vein sheath, allowing for lesion manipulation at a reduced embolic risk.…”

Section: Introductionmentioning

confidence: 99%

“…4,5 To accomplish this, sheaths are placed in the common carotid artery and the femoral vein and connected. 5 Next, the common carotid is clamped proximal to the arterial sheath, allowing the flow to reverse into an external circuit connected to the femoral vein sheath, allowing for lesion manipulation at a reduced embolic risk. 5,6 TCAR has several advantages when compared to traditional carotid revascularization techniques.…”

Section: Introductionmentioning

confidence: 99%

“…5 Next, the common carotid is clamped proximal to the arterial sheath, allowing the flow to reverse into an external circuit connected to the femoral vein sheath, allowing for lesion manipulation at a reduced embolic risk. 5,6 TCAR has several advantages when compared to traditional carotid revascularization techniques. It is minimally invasive, removes manipulation of the aortic arch, and introduces the concept of neuroprotection before lesion manipulation.…”

Section: Introductionmentioning

confidence: 99%

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Transcarotid Revascularization Results in Patients Over 70 Years of Age

Dias

Fajardo

Martin

et al. 2022

Objective Carotid endarterectomy is associated with fewer procedure-related strokes than transfemoral carotid artery stenting in older populations, based on the results from previous quality randomized controlled studies. Transcarotid artery revascularization (TCAR) is a hybrid procedure completed in the setting of cerebral flow reversal to deploy a stent, making it an appealing choice for older patients. This study was completed to elicit any age-related differences in outcomes after undergoing TCAR in patients 70 years of age and older. Methods A retrospective review was completed of a dual institutional database between December 2015 and April 2022 to capture demographics, comorbidities, and perioperative results. The geriatric cohort was defined at a cutoff of 70 years. Univariate statistical testing between groups were completed with Student’s T-test or Fisher’s exact test at an α of .05 for continuous and categorical variables, respectively. Results 851 procedures were captured for statistical analysis. With age cutoff of 70 years, we generated 567 geriatric (78.4 ± 5.7 years) and 284 young (63.2 ± 5.7 years) patients. The older patients tended to have more baseline illness, as measured by a higher rate Charlson Comorbidity Index (4.4 ± 2.2 vs 6.0 ± 2.1, P < .01). Younger patients tended to be actively smoking (42.3% vs 17.6%, P < .01). Intraoperative variables were grossly similar by age, including blood loss (43.0 ± 45.0 vs 45.7 ± 50.3 mLs, P = .45), reverse flow time (9.0 ± 7.4 vs 9.0 ± 6.7 mins, P = .98), and technical success (98.9% vs 98.6%, P = .76). While we observed an increased rate of stroke in the older patients, this did not reach statistical significance (1.4% vs 2.6%, P = .33). There were no differences between age groups with respect to myocardial infarction (0% vs .5%, P = .55) and death (1.1% vs 1.1%, P > .99) in the 30-day perioperative period. Conclusion We found that TCAR was not associated with age-related increases in adverse outcomes and can be considered a viable option when treating carotid artery stenosis in patients older than 70 years of age.

“…Transcarotid artery revascularization (TCAR) is a hybrid carotid procedure utilizing cerebral flow reversal to mitigate intraoperative plaque embolization during the course of carotid stenting. 1 While carotid endarterectomy (CEA) continues to be the gold-standard when it comes to carotid surgery, TCAR has been shown to be comparable 2 —or favorable 3,4 —in nonrandomized samples. This flow reversal technique was deemed safe and effective 5,6 and, thus, TCAR became commercially available in 2015.…”

Section: Introductionmentioning

confidence: 99%

Transcarotid Revascularization Timing and Early Postoperative Outcomes in Symptomatic Patients

Pineau

Fajardo

Saqib³

et al. 2022

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.