NESVS25. Most Patients Are Eligible for Transcarotid Revascularization Despite Its Anatomic Restrictions

Abstract

Transcarotid artery revascularization (TCAR) has emerged as an alternative to transfemoral carotid artery stenting (CAS). We evaluated how many patients with carotid stenosis would qualify for TCAR on the basis of anatomic criteria. We performed a retrospective review of consecutive patients who underwent carotid endarterectomy or CAS between 2012 and 2015. Patients were excluded if computed tomography angiography of the neck within 6 months of the procedure was unavailable. We assessed eligibility of the patients on the basis of the instructions for use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Patients were deemed ineligible for TCAR if the target internal carotid artery diameter was not between 4 and 9 mm, the clavicle to carotid bifurcation distance was <5 cm, or the intended common carotid artery (CCA) puncture site had significant plaque. We also evaluated the proportion of CCAs that had access site depth ≥4 cm because of the increased complexity of the procedure. Of 478 patients examined, 118 had preoperative computed tomography angiography. All carotid arteries had internal carotid artery diameters between 4 and 9 mm, 74% had a clavicle to carotid bifurcation ≥5 cm, and 96% had minimal or no plaque at the CCA puncture site, resulting in 72% of patients being eligible for TCAR. Of carotid arteries eligible for TCAR, 13% were considered more challenging, given CCA depth ≥4 cm; but of these arteries, only 3.4% had depth ≥4.5 cm, and 39% had a longer clavicle to bifurcation distance of >6 cm. Patients who were ineligible for TCAR were older (72.5 ± 6.8 years vs 69.1 ± 9.2 years; P < .01) and more often had hyperlipidemia (95.5% vs 80.5%; P < .01) and chronic obstructive pulmonary disease (25.4% vs 8.9%; P = .001) but were less likely to have diabetes (25.4% vs 40.8%; P< .03) or to be taking beta blockers (50.7% vs 65.1%; P = .04). Twenty percent of patients were at high risk for transfemoral CAS based on presence of type III aortic arch (7.2%), severe aortic arch calcification (4.5%), tandem CCA lesions (6.4%), or moderate to severe stenosis at the carotid ostium (9.7%). Of the transfemoral CAS high-risk patients, 63% were eligible for TCAR. Of patients >80 years old, 64% were eligible for TCAR. The majority of carotid arteries in patients selected for revascularization meet TCAR eligibility.