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June 19, 2020

TCAR With Dynamic Flow Reversal Studied in Patients With Contralateral Carotid Artery Occlusion

June 19, 2020—Hanaa Dakour-Aridi, MD, et al published a study of the outcomes of transcarotid artery revascularization (TCAR) with dynamic flow reversal in patients with contralateral carotid artery occlusion (CCO). The findings are available online ahead of print in Journal of Vascular Surgery (JVS).

According to the study abstract in JVS, CCO has been defined by the Centers for Medicare and Medicaid Services as a high-risk criterion and is used as an indication for transfemoral carotid artery stenting. Outcomes of carotid revascularization in patients with CCO are controversial. With the promising outcomes associated with TCAR, the investigators aimed to study the perioperative outcomes of TCAR in patients with CCO and assess the feasibility of TCAR in these high-risk patients.

All patients in the Vascular Quality Initiative data set who underwent TCAR with flow reversal between September 2016 and May 2019 were included in the study. However, the study excluded patients with trauma, dissection, or more than two treated lesions. The study was composed of a total of 5,485 TCAR patients, of which 593 (10.8%) had CCO.

The investigators used univariable and multivariable logistic analysis to compare the primary outcome of in-hospital stroke or death after TCAR in patients with CCO versus without CCO (patent and < 99% stenosis). Secondary outcomes included intraoperative neurologic changes; the individual outcomes of in-hospital stroke, death, and myocardial infarction (MI); and 30-day mortality.

As summarized in JVS, in patients with CCO, mean flow reversal time was shorter (10.1 ± 6.7 min vs 11.1± 7.8 min; P < .01), while intraoperative neurologic changes occurred in 1% of these patients compared with 0.7% of those with patent contralateral carotid arteries (P = .43).

On univariable analysis, no significant difference in in-hospital stroke or death was shown between patients with and without CCO (1.7% vs 1.5%; P = .65). Similarly, no significant differences were noted between the two groups in terms of in-hospital death (0.7% vs 0.4%; P = .27), stroke (1.7% vs 1.2%; P = .32), stroke/death/MI (2.2% vs 1.8%; P = .53), and 30-day mortality (0.8% vs 0.6%; P = .55).

The results remained statistically nonsignificant after adjusting for baseline differences between the two groups; the adjusted odds ratio of in-hospital stroke/death in patients with CCO compared to those with patent contralateral carotid arteries was not significant (odds ratio [OR], 1.39; 95% CI, 0.6-53; P = .4).

In symptomatic patients presenting with previous stroke, CCO was associated with significantly higher odds of stroke or death compared to no CCO (OR, 4.63; 95% CI, 1.39-15.4; P = .01). However, in asymptomatic patients, no significant difference in outcomes was observed between the two groups.

The investigators concluded that this analysis showed TCAR seems to be safe in patients with CCO. They advised that caution should be taken in symptomatic patients with CCO and a history of previous stroke because they might have worse outcomes compared to patients with patent contralateral carotid arteries.

Studies with larger sample sizes and longer follow-up are needed to assess the perioperative and long-term outcomes of TCAR in patients with CCO in comparison to other procedures, stated the investigators in JVS.

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