Outcomes of transcarotid revascularization with dynamic flow reversal versus carotid endarterectomy in the TCAR Surveillance Project

Abstract

Carotid endarterectomy remains the reference standard procedure for carotid revascularization in patients with significant carotid artery stenosis. However, carotid artery stenting was established as a minimally invasive procedure for patients who are not candidates for open surgery due to medical or anatomic high-risk factors. However, despite years of technical refinement and significant improvement in proper patient selection and aggressive medical management, carotid artery stenting via the transfemoral approach has been scrutinized due to a higher risk of stroke or death in the perioperative period compared with carotid endarterectomy. The higher risk of stroke after carotid artery stenting was attributed to manipulation of the diseased aortic arch and the carotid lesion before placement of distal embolic protection devices, as well as failure of these devices to provide adequate neuroprotection. These limitations led to the development of transcarotid artery revascularization, which avoids the need to cross the aortic arch through direct access to the common carotid artery and utilizes a robust neuroprotection mechanism through clamping the proximal carotid artery and establishing active reversal of cerebral blood flow to clear embolic debris. Earlier studies have demonstrated favorable outcomes after transcarotid artery revascularization in high-risk patients. In this study, we aimed to compare the in-hospital outcomes of transcarotid artery revascularization with those of carotid endarterectomy in patients with symptomatic and asymptomatic carotid artery stenosis.