Transcarotid artery revascularization as a new modality of treatment for cartoid stenosis

Abstract

Background: Carotid artery stenosis is a significant cause of ischemic stroke, and studies have shown that transfemoral carotid artery stenting is associated with a higher perioperative stroke risk than open endarterectomy. Transcarotid artery revascularization (TCAR) is a novel technique in carotid stenting via direct transcervical carotid access without the risk of arch manipulation, offers a smaller wound compared with endarterectomy, and employs flow reversal to decrease the risk of antegrade embolic stroke. Contemporary evidence on the safety and efficacy of TCAR is reviewed.

Methods: A systematic literature review on TCAR from January 2009 to August 2019 was performed in PubMed and EMBASE databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Clinical studies on TCAR with flow reversal with clinical outcomes of stroke, myocardial infarction (MI), and death were included.

Results: Initial search of the literature yielded 161 articles, of which 8 studies were included comprising of 5 single-arm studies and 3 comparative studies. Studies demonstrated high technical success rates of TCAR from 90.6% to 100%, with low perioperative stroke, MI, and mortality rates of 0 to 4%, 0 to 0.7% and 0 to 2.7%, respectively. TCAR was significantly associated with a lower in-hospital stroke/transient ischemic attack rate when compared to transfemoral carotid stenting. There was no significant difference in perioperative stroke/MI/death when compared to endarterectomy although TCAR had a significantly lower risk of cranial nerve injury.

Conclusions: TCAR with flow reversal is a promising treatment option for carotid occlusive disease. Clinical trials are currently underway to provide a better report on outcomes of TCAR and for further comparison between TCAR and carotid endarterectomy.