TransCarotid Revascularization With Dynamic Flow Reversal Versus Carotid Endarterectomy in the Vascular Quality Initiative Surveillance Project

Abstract

Objective: To compare the outcomes of TCAR with flow reversal to the gold standard CEA using data from the Society for Vascular Surgery Vascular Quality Initiative TCAR Surveillance Project. Summary of Background Data: TCAR is a novel minimally invasive procedure for carotid revascularization in high-risk patients that is associated with significantly lower stroke rates compared with carotid artery stenting via the transfemoral approach. Methods: Patients in the United States and Canada who underwent TCAR and CEA for carotid artery stenosis (2016-2019) were included. Propensity scores were calculated based on baseline clinical variables and used to match patients in the 2 treatment groups (n = 6384 each). The primary endpoint was the combined outcome of perioperative stroke and/or death.Results: No significant differences were observed between TCAR and CEA in terms of in-hospital stroke/death [TCAR, 1.6% vs CEA, 1.6%, RR (95% CI): 1.01 (0.77-1.33), P = 0.945], stroke [1.4% vs 1.4%, RR (95% CI): 1.02 (0.76-1.37), P = 0.881], or death [0.4% vs 0.3%, RR (95% CI): 1.14 (0.64-2.02), P = 0.662]. Compared to CEA, TCAR was associated with lower rates of in-hospital myocardial infarction [0.5% vs 0.9%, RR (95% CI): 0.53 (0.35-0.83), P = 0.005], cranial nerve injury [0.4% vs 2.7%, RR (95% CI): 0.14 (0.08-0.23), P < 0.001], and postprocedural hypertension [13% vs 18.8%, RR (95% CI): 0.69 (0.63-0.76), P < 0.001]. They were also less likely to stay in the hospital for more than 1 day [26.4% vs 30.1%, RR (95% CI): 0.88 (0.82-0.94), P < 0.001]. No significant interaction was observed between procedure and symptomatic status in predicting postoperative outcomes. At 1 year, the incidence of ipsilateral stroke or death was similar between the 2 groups [HR (95% CI): 1.09 (0.87-1.36), P = 0.44]. Conclusions: This propensity-score matched analysis demonstrated significant reduction in the risk of postoperative myocardial infarction and cranial nerve injury after TCAR compared to CEA, with no differences in the rates of stroke/death.

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

“…44 In another study by Malas et al, TCAR was also associated with lower risk of post-operative hypertension and reduced length of hospital stay compared with CEA. 45 Regarding the effect of symptoms on major outcomes, an almost double early stroke/TIA risk was found in symptomatic patients compared with asymptomatic patients. This difference between symptomatic and asymptomatic patients is also observed among patients undergoing CEA or tfCAS.…”

Carotid Revascularization Procedural Volume and Perioperative Outcomes

“…TransCarotid Artery Revascularization is associated with similar perioperative stroke/death outcomes compared with CEA, while mitigating the risk of cranial nerve injury. [14][15][16] There is also evidence that TCAR achieves considerably better perioperative outcomes compared with transfemoral CAS. 17 Thus, future international guidelines regarding the management of patients with asymptomatic and symptomatic carotid stenosis (eg, the upcoming SVS guidelines) may consider reducing the (outdated and excessively high) current risk threshold, for example, to <2% and <4%, for asymptomatic and symptomatic carotid patients, respectively (or perhaps even lower).…”

“…12,13 Transfemoral CAS is gradually becoming obsolete with the availability of TCAR. [14][15][16][17] Increasing physician expertise/procedural volume will hopefully lead to even lower perioperative stroke/ death rates after CEA/CAS in the future. The findings of the study by Giurgius et al 1 support earlier reports suggesting that physicians with increased volume achieve lower perioperative stroke/death rates with CEA/CAS.…”

Carotid artery stenosis and stroke: controversies in prevention and treatment

“…Although CAS has emerged as a less invasive alternative to CEA, data from real-world clinical studies suggest that CAS is associated with considerably higher stroke/death rates compared with CEA and is therefore not an equal alternative to CEA for many carotid patients (14,16). Fortunately, a novel technique called transcarotid artery revascularization (TCAR) with carotid flow reversal, has already demonstrated some promising results (17,18) and may hopefully provide the answer for high-risk patients requiring a carotid revascularization procedure. Current evidence suggests that TCAR is associated with similar outcomes when compared with the gold standard, CEA (17,18).…”

“…Fortunately, a novel technique called transcarotid artery revascularization (TCAR) with carotid flow reversal, has already demonstrated some promising results (17,18) and may hopefully provide the answer for high-risk patients requiring a carotid revascularization procedure. Current evidence suggests that TCAR is associated with similar outcomes when compared with the gold standard, CEA (17,18). A randomized controlled trial in the Editorial future comparing CEA vs. TCAR is essential to establish TCAR as an effective treatment modality for carotid stenosis patients.…”