Outcomes and insights from a decade of transcarotid artery revascularization in community practice

Abstract

Objective: Transcarotid arterial revascularization (TCAR) with flow reversal is a well-established minimally invasive alternative to carotid endarterectomy. Our multicenter, private practice is an early adopter and has performed TCARs in the community since 2013. We report our real-world experience after performing 650 TCARs over 10 years in the community.

Methods: We performed 655 TCAR procedures on 588 patients between 2013 and 2024. A retrospective chart review was performed on these procedures. The cohort included 9 vascular surgeons across 10 hospitals. All procedures used the enroute transcarotid neuroprotection system, which uses common carotid access and high-rate flow reversal as embolic protection during stenting. The primary end points for this study are 30-day rates of stroke and myocardial infarction. Secondary end points included operative time, cranial nerve injury, neck hematoma requiring evacuation, arterial dissection, and death.

Results: We performed 655 TCAR procedures on 588 unique patients. At the time of surgery, 403 patients (61.52%) were asymptomatic. The median patient age was 73 years (interquartile range, 67-79 years). Patient medical history, surgical history, predilation and postdilation balloon sizes, stent sizes, operative time, flow reversal time, contrast volume, reoperation status, discharge statin, and anticoagulation therapies are listed and summarized in the tables. Eleven patients suffered a perioperative stroke (1.68%) within 30 days of the operations, and 10 (1.53%) suffered a stroke after 30 days but within 1 year of the operation. Myocardial infarction occurred in one patient (0.15%) within 30 days and six (0.91%) within 1 year. Cranial nerve injury occurred in 10 (1.52%) patients, defined as either dysphagia (n = 1) or hoarseness (n = 9). Neck hematoma with evacuation occurred in 10 patients (1.53%). An arterial dissection transpired in a single patient (0.15%).

Conclusions: Over the last decade, TCAR has emerged as an effective and efficient first-line therapy for treating suitable patients with carotid artery stenosis regularly in less than 1 hour of operative time. Early adoption and integration of this technology into practice have yielded excellent patient outcomes, matching or surpassing those reported in the literature for the gold standard, carotid endarterectomy.

Keywords: Carotid artery disease; Carotid artery stenosis; Community care; Stroke; Vascular surgery.