PC094. The Expanding Role of Transcarotid Artery Revascularization in Patients With Carotid Occlusive Disease and High-Risk Anatomic Features

Abstract

Transcarotid artery revascularization (TCAR) has emerged as an alternative to carotid endarterectomy (CEA) by combining an open transcervical approach with cerebral flow reversal to facilitate carotid artery stenting. The aim of this study was to compare short-term outcomes of TCAR vs CEA in current practice. Patients undergoing TCAR and CEA between January 2014 and December 2017 were retrospectively evaluated. Concomitant carotid-coronary revascularization and nonocclusive indications were excluded. High-risk anatomic features (ie, prior irradiation/radical neck surgery, high lesion [≥C2 level], and prior ipsilateral CEA) were studied between the treatment groups. Primary end points were 30-day stroke rate, myocardial infarction (MI), and mortality. Overall, 87 patients underwent TCAR and 468 patients underwent CEA. Patients who underwent TCAR were older (74 vs 70 years; P = .001) and predominantly male (72% vs 53%; P = .001). There was no difference between groups for patients treated for symptomatic stenosis (47% vs 52%; P = .42). The TCAR group had a significantly higher prevalence of congestive heart failure (40% vs 26%; P = .007), chronic anticoagulation (20% vs 9%; P = .004), and tobacco exposure (86% vs 79%; P = .007). TCAR patients had a higher prevalence of at least one high-risk anatomic feature (31% vs 6%; P < .001) including prior irradiation (7% vs 2%; P = .004), radical neck surgery (13% vs 3%; P < .001), prior ipsilateral CEA (14% vs 1%; P < .001), and high lesion (9% vs 1 %; P < .001). Patients undergoing TCAR were more likely to have contralateral occlusions (14% vs 5%; P = .002) and contralateral carotid stenosis >80% (13% vs 6%; P = .04). TCARs were more commonly performed under local anesthesia (34% vs 19%; P = .001). There was a trend toward decreased cranial nerve injuries in TCAR compared with CEA (1% vs 6%; P = .057). The incidences of postoperative MI (1% vs 1%; P = .8), stroke (1% vs 1%; P = .8), combined stroke-MI (5% vs 4%; P = .8), and 30-day mortality (0 vs 3/453 [0.67%]; P = .4) were similar between TCAR and CEA. In a large multicenter vascular surgery practice, TCAR is associated with similar 30-day stroke, myocardial infarction, combined MI-stroke, and mortality rates compared wutg CEA despite a higher incidence of high-risk anatomic criteria in patients undergoing TCAR.