Transcarotid artery revascularization versus transfemoral carotid artery stenting in the Society for Vascular Surgery Vascular Quality Initiative

Abstract

Compared with patients undergoing TFCAS, patients undergoing TCAR had significantly more medical comorbidities but similar stroke/death rates and half the risk of in-hospital TIA/stroke/death. These results persisted despite rigorous adjustment and matching of potential confounders. This initial evaluation of the VQI TSP demonstrates the ability to rapidly monitor new devices and procedures using the VQI. Although it is preliminary, this is the first study to demonstrate the benefit of TCAR compared with TFCAS in real-world practice. These results need to be confirmed by a clinical trial.

Learning Curve for Surgeons Adopting Transcarotid Artery Revascularization Based on the Vascular Quality Initiative-Transcarotid Artery Revascularization Surveillance Project

“…Transcarotid artery revascularization is becoming an accepted alternative to TF-CAS because of its superior stroke and death rates produced in multiple studies. [8][9][10][11][12]20 This study suggests that the procedure has a short learning curve and more importantly, that patients in the early experience are not at risk for inferior outcomes. With increasing experience, operative, flow reversal, and fluoroscopy times, and the use of general anesthesia all decrease.…”

“…Transcarotid artery revascularization (TCAR) has been shown to be an effective alternative to transfemoral carotid artery stenting (TF-CAS). [8][9][10][11][12] The direct surgical access of the common carotid artery paired with highrate carotid blood flow reversal eliminate the inherent risks of TF-CAS. 13 The pivotal and extended access data from the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROAD-STER) multicenter trial achieved one of the lowest 30-day stroke rates (1.4%) of any prospective, multicenter carotid artery stenting trial.…”

Contemporary outcomes after carotid endarterectomy in high-risk anatomic and physiologic patients

“…Initial data from the SVS VQI TCAR Surveillance Project, which is an ongoing collaborative effort between the SVS, Food and Drug Administration, and CMS to evaluate the outcomes after TCAR in centers participating in the VQI, found TCAR to be equivalent to CEA and safer than transfemoral CAS, with half the odds of in-hospital adverse neurologic events. 9,10 Although the majority of patients currently treated with TCAR have high medical or anatomic risk, the specific outcome after TCAR treatment in populations of high-risk patients is currently unknown and warrants further study.…”

Reply

“…As stated in the paper, the lack of statistical significance in major end points such as stroke and death between TCAR and transfemoral carotid artery stenting is due to the small number of patients included in the study and the low event rate. 1 We know that with the inclusion of more centers and operators in this project as well as with the dramatic recent increase in sample size to >3000 patients and availability of 30-day and long-term follow-up, the ongoing study has enough power to detect significant differences in stroke and stroke/death between the two procedures. A more recent updated publication is ongoing to reflect these findings.…”

“…We greatly appreciate Dr Naylor's interest in our work on transcarotid artery revascularization (TCAR) with dynamic flow reversal. 1 The TCAR Surveillance Project (TSP) is an ongoing project by the Society for Vascular Surgery Vascular Quality Initiative to assess the safety and effectiveness of TCAR in real-world practice. By 2024, the TSP is estimated to include 15,000 participants.…”