TCAR may be associated with favorable outcomes in restenotic carotid lesions, study suggests

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Mahmoud B. Malas

Transcarotid artery revascularization (TCAR) may be associated with favorable in-hospital outcomes for the treatment of restenotic carotid lesions after carotid endarterectomy (CEA), suggests a study that also evaluated in-hospital outcomes of transfemoral carotid artery stenting (TFCAS) and redo-CEA.

Writing in the journal Stroke, Mahmoud B. Malas, MD, chief of vascular and endovascular surgery at UCSD [University of California San Diego], San Diego, et al describe the design and results of a non-randomized, retrospective analysis of patients undergoing treatment for post-CEA restenosis. Despite this indication being linked to an increased risk of ipsilateral stroke, an optimal procedural modality for it has yet to be determined, they note.

The study’s researchers analyzed a large contemporary cohort of patients in the vascular quality initiative (VQI) database—a prospectively maintained database containing patient- and procedure-specific data from more than 700 centers across the U.S. and Canada—who underwent TCAR, redo-CEA, or TFCAS, after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral carotid artery stenting (CAS) were excluded.

The primary outcome in this study was the composite endpoint of in-hospital stroke or death, with secondary endpoints being in-hospital stroke, death, myocardial infarction (MI), the composite endpoint of stroke or transient ischemic attack (TIA), and the composite endpoint of stroke, death, or MI. For the purposes of the study, strokes included any ipsilateral or contralateral cortical or vertebrobasilar stroke, TIAs included any ipsilateral or contralateral TIA, and MI was diagnosed based on elevated troponin levels or electrocardiogram (ECG) changes.

The final patient cohort included a total of 4,425 patients—1,676 TCAR (37.9%), 1,786 TFCAS (40.4%), and 963 redo-CEA (21.8%) patients. TCAR, despite a “considerably higher burden of comorbidities”, was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% confidence interval [CI], 0.24–0.70], p=0.021), stroke (OR, 0.46 [95% CI, 0.23–0.93], p=0.03), MI (OR, 0.32 [95% CI, 0.14–0.73], p=0.007), stroke/TIA (OR, 0.42 [95% CI, 0.24–0.74], p=0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24–0.70], p=0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the two groups (OR, 0.99 [95% CI, 0.28–3.5], p=0.995), Malas et al also report. TCAR was associated with lower odds of stroke/TIA (OR, 0.37 [95% CI, 0.18–0.74], p=0.005) when compared with TFCAS too—although there was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI, between TCAR and TFCAS.

“To our knowledge, this is the first and largest study of its kind to demonstrate better perioperative outcomes with TCAR when compared with both TFCAS and redo-CEA in the treatment of recurrent carotid disease after endarterectomy,” Malas and colleagues write. “The significant differences in primary and secondary endpoints between TCAR and redo-CEA were evident despite adjustment for patient characteristics, and several potential confounders.”

In addition, they note that—although they are unable to establish causal determinants for the unfavorable outcomes associated with redo-CEA—they believe this may be due to longer surgery times with increased manipulation of the carotid bifurcation, and prolonged general anesthetic exposure, but it could also relate to lesion or anatomic characteristics that increased case complexity and therefore precluded minimally invasive intervention. When compared with TFCAS, they add, redo-CEA was associated with higher mortality but similar rates of stroke and MI. Thus, they recommend avoidance of redo-CEA in high-risk patients, and assert that “the findings in our study align with the prior literature and raise questions regarding the role of redo-CEA in the treatment of recurrent carotid disease after endarterectomy.”

They also report that their study found patients undergoing TCAR, when compared with TFCAS, were more likely to be older (aged over 75 years), have coronary artery disease, be in higher American Society of Anesthesiologists classes (IV–V), and receive general anesthesia. Malas et al add that, notably, TCAR was associated with a 60% reduction in the odds of stroke/TIA when compared with TFCAS and—after stratifying by symptomatic status—was associated with a 70% reduction in the odds of in-hospital stroke, a 90% reduction in the odds of in-hospital stroke/TIA, and 50% and 60% reductions in the odds of stroke/death and stroke/death/MI in the asymptomatic group, although no significant difference was observed among symptomatic patients. These favorable outcomes may be due to the technical advantages of TCAR, they claim, referencing its utilization of dynamic flow reversal, which reduces cerebral microembolization.

“Whereas in-hospital outcomes from a prospective registry are not sufficient to demonstrate the overall, long-term benefit of any specific revascularization technique, they provide a real-world evaluation of periprocedural risks and how they differ based on patient demographics and comorbidities,” the authors write, before concluding that—while their findings support the notion that TCAR might be associated with favorable outcomes for the treatment of restenotic carotid lesions—additional long-term studies are warranted “before we can establish the best procedural therapy for the treatment of restenosis after CEA.”

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