Transcarotid artery revascularization offers similar in-hospital outcomes to surgery
Compared with carotid endarterectomy, transcarotid artery revascularization was associated with similar in-hospital outcomes in patients with carotid stenosis, according to data presented at the Society for Vascular Surgery Vascular Annual Meeting.
Transcarotid artery revascularization (TCAR), which involves direct access via the carotid artery and cerebral protection with a flow-reversal system (Enroute, Silk Road Medical), has emerged as an alternative to transfemoral-access carotid artery stenting due to reduced risk for short-term stroke, Marc L. Schermerhorn, MD, chief of the division of vascular and endovascular surgery at Beth Israel Deaconess Medical Center and professor of surgery at Harvard Medical School, said during a presentation.
Schermerhorn and colleagues analyzed 1,182 patients who underwent TCAR (median age, 74 years; 63% men) and 10,797 patients who underwent carotid endarterectomy (median age, 71 years; 60% men) between January 2016 and March 2018 and were included in the SVS Vascular Quality Initiative TCAR Surveillance Project or endarterectomy databases.
The main purpose of the TCAR Surveillance Project was to analyze 1-year outcomes, but “we chose to do a preliminary early analysis for several reasons, including that many published trials report perioperative outcomes, and those are the numbers people often focus on because most of the events occur early on,” Schermerhorn told Cardiology Today’s Intervention.
The primary outcome was in-hospital stroke or death. Secondary outcomes included stroke/death/MI together and individually, 30-day mortality, access-site bleeding, cranial nerve injury, hyperperfusion syndrome and operative time.
Compared with the surgery group, the TCAR group was older, was more likely to be symptomatic and had more comorbidities, Schermerhorn told Cardiology Today’s Intervention, noting that this was expected because TCAR was only performed in patients deemed to be at high risk for endarterectomy.
Despite these differences, in unadjusted outcomes, the groups were similar in in-hospital stroke or death (TCAR, 1.6%; surgery, 1.4%; P = .33), stroke/death/MI (P = .16), stroke (P = .68), transient ischemic attack (P = .11), in-hospital mortality (P = .88), 30-day mortality (P = .06) and MI (P = .11).
“All of these were no different, despite the fact that TCAR patients were older, had more cardiac disease and renal disease and were more likely to be symptomatic with a higher degree of stenosis,” Schermerhorn said in an interview. “The fact that in unadjusted analysis, TCAR patients did as well as surgery patients is very strong.”
Compared with the surgery group, the TCAR group had lower rates of cranial nerve injury (P < .001), less need for IV antihypertensive medications (P < .001), shorter operative time (P < .001) and less likelihood of a length of stay longer than 1 day (P = .046), according to the researchers.
“Since everything else was the same, these are the factors that would push you a little bit more toward TCAR,” Schermerhorn said.
There were no significant differences between the groups in access-site bleeding or hyperperfusion syndrome.
After multivariable adjustment, there remained no significant differences between the groups in in-hospital stroke or death (OR = 0.8; 95% CI, 0.4-1.3), stroke/death/MI (OR = 0.7; 95% CI, 0.5-1.1), stroke (OR = 0.7; 95% CI, 0.4-1.3), in-hospital mortality (OR = 1.4; 95% CI, 0.5-3.8), 30-day mortality (OR = 0.7; 95% CI, 0.3-1.5) or MI (OR = 0.7; 95% CI, 0.3-1.4), Schermerhorn said.
“The fact that the high-risk patients did as well with TCAR as the entirety of the endarterectomy patients bodes well for TCAR,” Schermerhorn said in an interview. – by Erik Swain
Schermerhorn ML, et al. Abstract VESS05. Presented at: Society for Vascular Surgery Vascular Annual Meeting; June 20-23, 2018; Boston.
Disclosure: Schermerhorn reports he has consulted for Abbott on a matter unrelated to the present study.