July 22, 2019
Published Early Results From Matched Analysis Show Similar Risks for TCAR and CEA
July 23, 2019 – The Society for Vascular Surgery (SVS) announced the publication of the first report of a matched analysis of transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA), revealing a similar incidence of stroke and death at 30 days and 1 year. The study was published by Vikram S. Kashyap, MD, et al in Journal of Vascular Surgery (JVS; 2019;70:123–129).
According to the SVS announcement by Paul DiMuzio, MD, Assistant Editor of JVS, the study’s findings suggest that TCAR could become an important part of the vascular surgeon’s armamentarium in treating significant carotid stenosis. The SVS announcement noted that TCAR can be considered a hybrid of CEA and transfemoral carotid artery stenting (TF-CAS). Because TCAR does not require crossing the aortic arch and establishes neuroprotection before manipulation of the carotid lesion, it may offer less neurologic complications than TF-CAS.
As summarized in the SVS press release, the multicenter investigation was led by Dr. Kashyap, who is from University Hospitals, Cleveland Medical Center in Cleveland, Ohio. The study compared the 30-day and 1-year outcomes of CEA and TCAR. Investigators studied 663 patients who underwent either CEA (n = 371) or TCAR (n = 292) at four centers between 2013 and 2017.
After propensity matching the 292 TCAR patients with 292 CEA patients, they found similar rates of 30-day stroke (1% vs 0.3%; P = .62), 30-day mortality (0.3% vs 0.7%; P = NS), 1-year stroke (2.8% vs 2.2%; P = .79), and 1-year mortality (1.8% vs 4.5%; P = NS).
The composite endpoint of stroke/death/myocardial infarction at 1 month was 2.1% for TCAR versus 1.7% for CEA (P = NS). Additionally, TCAR was noted to have a lower rate of cranial nerve injury (0.3% vs 3.8%; P = .01).
In the SVS announcement, Dr. Kashyap commented, “Given that the broad cardiovascular and neurologic outcomes were similar between TCAR and CEA in this analysis, one may question which intervention to offer to patients with severe carotid bifurcation disease. A possible benefit of TCAR is the low rate of cranial nerve injury given the limited common carotid artery exposure needed for this procedure.”
He further noted, “TCAR has a mean procedural time of 75 ± 24 minutes. If one views the flow reversal time as the critical time-sensitive period during TCAR—analogous to clamping the carotid artery—this time for TCAR averages 11 ± 8 minutes.”