A systematic review and meta-analysis has found that transcarotid artery revascularisation (TCAR) is associated with “promising early and late outcomes” in patients with internal carotid artery stenosis, although symptomatic patients still carry a higher risk of early cerebrovascular events. This is the conclusion of George C Galyfos (Hippocration Hospital, Athens, Greece) and colleagues, whose work was published as an Editor’s Choice paper in the European Journal of Vascular and Endovascular Surgery (EJVES).
The authors state that either carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS) are usually recommended for the treatment of significant carotid stenosis. However, they note that both techniques have certain limitations. “Open surgery is associated with higher surgical stress, and could be the cause of the higher cardiac risk compared with stenting,” they elaborate, while tfCAS, on the other hand, carries the risk of intraoperative embolisation and chronic renal insufficiency, among others.
“[TCAR] offers an alternative strategy in patients where CEA or transfemoral stenting face difficulties,” Galyfos et al write. This review aimed to evaluate pooled data on patients undergoing TCAR and—in contrast to other similar reviews— evaluates both early and late outcomes as well as the effect of preoperative symptoms on early stroke/transient ischaemic attach (TIA), the authors detail.
The investigators searched the Medline, Embase, Scopus, and Cochrane Library databases for eligible studies. For a study to be included in the review, it had to have been published online by September 2020 and to have reported 30-day mortality and stroke/TIA rates in patients undergoing TCAR. Data were pooled in a random effects model and weight of effect for each study was also reported.
Writing in EJVES, the authors relay that they included eighteen studies in their analysis, comprising a total of 4,852 patients or 4,867 procedures. In terms of the quality of the included studies, the research team specify that eight were of a high standard, with seven meeting the criteria for a medium-quality study, and the remaining three a low-quality study.
Galyfos and colleagues report that the pooled 30-day mortality rate was 0.7% (n=32; 95% confidence interval [CI], 0.5–1), the 30-day stroke rate 1.4% (n=62; 95% CI, 1–1.7), and the 30-day stroke/TIA rate 2% (n=92; 95% CI, 1.4–2.7). They add that pooled technical success was 97.6% (95% CI, 95.9–98.8).
In terms of other outcomes, the investigators communicate that the cranial nerve injury rate was 1.2% (n=14; 95% CI, 0.7–1.9) while the early myocardial infarction rate was 0.4% (n=16; 95% CI, 0.2–0.6). The haematoma/bleeding rate was 3.4% (n=135; 95% CI, 1.7–5.8), they convey, noting that one-third of these cases needing drainage or intervention. They also reveal that, within a follow-up for three to 40 months, the restenosis rate was 4% (n=64/530; 95% CI, 0.1–13.1) and death/stroke rate 4.5% (n=184/3,742; 95% CI, 1.8–8.4).
Considering symptomatic patients specifically, Galyfos et al found that this subgroup had a higher risk of early stroke/TIA than asymptomatic patients (2.5% vs. 1.2%; odds ratio, 1.99; 95% CI, 1.01–3.92); p=0.046).
The authors acknowledge some limitations of this review, including the retrospective nature of the majority of included studies—despite most being of medium to high quality—almost three-quarters of the patients originating from the Vascular Quality Initiative (VQI), and there being insufficient data to conduct certain subgroup analyses, such as for diabetic patients.
Galyfos and colleagues conclude that TCAR is a “promising method” for treating internal carotid artery disease as it is associated with a low rate of early death, stroke, and other complications. However, they stress that symptomatic patients have a higher risk of early cerebrovascular events when this technique is used. In closing, the authors consider the direction of future research: “Prospectively designed studies comparing outcomes between TCAR and CEA in symptomatic patients are needed to further evaluate the benefit of this technique”.