Treatment of Carotid Restenosis Using Transcarotid Revascularization

Abstract

Objective: Transcarotid artery revascularization (TCAR) using the ENROUTE Neuroprotection System (Silk Road Medical) is a United States Food and Drug Administration–approved treatment modality for stroke risk reduction in the setting of carotid artery stenosis. The goal of this investigation was to define the real-world outcomes associated with the application of this technique to patients presenting with restenosis after previous carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TF-CAS). Methods: Retrospective review of prospectively maintained institutional databases capturing all nontrial TCARs performed between August 2013 and July 2018 using the ENROUTE Neuroprotection System was completed at 3 unaffiliated hospital systems and unified for descriptive outcomes analysis. Results: During the study period, 237 combined TCARs were performed at our respective institutions. Of these procedures, 55 stents were implanted for the indication of restenosis after previous carotid revascularization (47 CEA, 8 TF-CAS). Within the 30-day perioperative period, we observed no ipsilateral strokes or deaths; one patient experienced perioperative myocardial infarction (MI; 1.8%). We noted a 4.8% incidence of postoperative hematoma, but none of these events were clinically significant as no reinterventions were performed in any of the 55 patients. Additionally, we did not observe any cases of stent thrombosis or pulmonary embolus. Mean length of stay was 2.2 ± 2.8 days. Our mean follow-up duration was 15.0 ± 9.2 months. Throughout the follow-up period, we did not observe any additional stroke or MI events. Additionally, there were no cases of in-stent restenosis, thrombosis, or reinterventions. Conclusion: Transcarotid artery revascularization can be performed in patients with restenotic carotid arteries with acceptable rates of ipsilateral stroke, MI, and death as demonstrated in this small multi-institutional series.

Outcomes of transcarotid artery revascularization: A systematic review

“…35 TCAR has also been preliminarily proved to be safe in the treatment of carotid artery restenosis and carotid artery aneurysm. 36,37 At present, TCAR provides a new option for the restenosis treatment after CEA and TFCAS. 38 Also, two case reports have demonstrated that TCAR could be used to treat carotid artery pseudoaneurysm and outcomes were satisfying.…”

Cost-effectiveness of transcarotid artery revascularization versus carotid endarterectomy

“…[14][15][16][17] Multiple national studies have also demonstrated the safety and efficacy of TCAR in high-risk patients, irrespective of age, symptomatic status, contralateral carotid occlusions, and restenotic lesions. [18][19][20][21][22][23][24] Although the clinical benefits of TCAR have been clearly established, there is a paucity of literature comparing its cost-effectiveness with that of CEA. This is particularly pertinent as health care costs currently represent 18% of U.S.…”

Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy

“…[16][17][18][19][20] However, for the treatment of restenosis after CEA, a review of the literature reveals a single, promising multi-institutional experience of 55 patients receiving TCAR with no comparison arms. 21 The aim of this study is to use real-world national data from the vascular quality initiative (VQI) to compare the outcomes of TCAR, TFCAS, and redo-CEA in patients undergoing treatment for restenosis after CEA.…”