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WHAT THIS PAPER ADDSThis systematic review summarises the evidence for transcarotid revascularisation (TCAR) in patients with internal carotid artery stenosis. This technique offers an alternative strategy in patients where carotid endarterectomy (CEA) or transfemoral stenting face difficulties. This review evaluates early and late outcomes of the method in contrast to other similar reviews. Data indicate that TCAR is safe and efficient although symptomatic patients still carry a higher risk of early cerebrovascular complications. Prospectively designed studies comparing outcomes between TCAR and CEA in symptomatic patients are needed to further evaluate the benefit of this technique.Objective: Transcarotid/transcervical revascularisation (TCAR) is an alternative to carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS). This review aimed to evaluate pooled data on patients undergoing TCAR. Data sources: Medline, Embase, Scopus, and Cochrane Library databases were used. Review methods: This systematic review was conducted under Systematic Reviews and Meta-Analysis guidelines. Eligible studies (published online up to September 2020) reported 30 day mortality and stroke/transient ischaemic attack (TIA) rates in patients undergoing TCAR. Data were pooled in a random effects model and weight of effect for each study was also reported. Quality of studies was evaluated according to Newcastle e Ottawa scale. Results: Eighteen studies (three low, seven medium, and eight high quality) included 4 852 patients (4 867 TCAR procedures). The pooled 30 day mortality rate was 0.7% (n ¼ 32) (95% confidence interval [CI] 0.5 e 1.0), 30 day stroke rate 1.4% (n ¼ 62) (95% CI 1.0 e 1.7), and 30 day stroke/TIA rate 2.0% (n ¼ 92) (95% CI 1.4 e 2.7). Pooled technical success was 97.6% (95% CI 95.9 e 98.8). The cranial nerve injury rate was 1.2% (95% CI 0.7 e 1.9) (n ¼ 14; data from 10 studies) while the early myocardial infarction (MI) rate was 0.4% (95% CI 0.2 e 0.6) (n ¼ 16; data from 17 studies). The haematoma/bleeding rate was 3.4% (95% CI 1.7 e 5.8) (n ¼ 135; data from 10 studies), with one third of these cases needing drainage or intervention. Within a follow up of 3 e 40 months the restenosis rate was 4% (95% CI 0.1 e 13.1) (data from nine studies; n ¼ 64/530 patients) and death/stroke rate 4.5% (95% CI 1.8 e 8.4) (data from five studies; n ¼ 184/3 742 patients). Symptomatic patients had a higher risk of early stroke/TIA than asymptomatic patients (2.5% vs. 1.2%; odds ratio 1.99; 95% CI 1.01 e 3.92); p ¼ .046; data from eight studies). Conclusion: TCAR is associated with promising early and late outcomes, with symptomatic patients having a higher risk of early cerebrovascular events. More prospective comparative studies are needed in order to verify TCAR as an established alternative treatment technique.

Objective: Transcarotid/transcervical revascularisation (TCAR) is an alternative to carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS). This review aimed to evaluate pooled data on patients undergoing TCAR.Data sources: Medline, Embase, Scopus, and Cochrane Library databases were used.Review methods: This systematic review was conducted under Systematic Reviews and Meta-Analysis guidelines. Eligible studies (published online up to September 2020) reported 30 day mortality and stroke/transient ischaemic attack (TIA) rates in patients undergoing TCAR. Data were pooled in a random effects model and weight of effect for each study was also reported. Quality of studies was evaluated according to Newcastle e Ottawa scale.Results: Eighteen studies (three low, seven medium, and eight high quality) included 4 852 patients (4 867 TCAR procedures). The pooled 30 day mortality rate was 0.7% (n = 32) (95% confidence interval [CI] 0.5 e 1.0), 30 day stroke rate 1.4% (n = 62) (95% CI 1.0 e 1.7), and 30 day stroke/TIA rate 2.0% (n = 92) (95% CI 1.4 e 2.7). Pooled technical success was 97.6% (95% CI 95.9 e 98.8). The cranial nerve injury rate was 1.2% (95% CI 0.7 e 1.9) (n = 14; data from 10 studies) while the early myocardial infarction (MI) rate was 0.4% (95% CI 0.2 e 0.6) (n = 16; data from 17 studies). The haematoma/bleeding rate was 3.4% (95% CI 1.7 e 5.8) (n = 135; data from 10 studies), with one third of these cases needing drainage or intervention. Within a follow up of 3 e 40 months the restenosis rate was 4% (95% CI 0.1 e 13.1) (data from nine studies; n = 64/530 patients) and death/stroke rate 4.5% (95% CI 1.8 e 8.4) (data from five studies; n = 184/3 742 patients). Symptomatic patients had a higher risk of early stroke/TIA than asymptomatic patients (2.5% vs. 1.2%; odds ratio 1.99; 95% CI 1.01 e 3.92); p = .046; data from eight studies).Conclusion: TCAR is associated with promising early and late outcomes, with symptomatic patients having a higher risk of early cerebrovascular events. More prospective comparative studies are needed in order to verify TCAR as an established alternative treatment technique.

A 64-year-old man was referred to the vascular surgery department with an incidental finding of right internal carotid artery stenosis during thyroid ultrasound imaging. Carotid artery color duplex revealed an ulcerated type III plaque producing stenosis of the right internal carotid artery of 70% and agenesis of the left internal carotid artery. Further imaging with computed tomography angiography confirmed the initial findings and excluded cerebral vascular malformations and ischemic cerebral infarcts. The patient was treated with endarterectomy of the right internal carotid artery with elective shunting and synthetic patch closure. (J Vasc Surg Cases 2015;1:254-7.) Congenital abnormalities of the internal carotid arteries (ICAs) in the form of agenesis, aplasia, or hypoplasia, refer to a group of dysgenesias during embryonic development. Prevalence in the general population is rare, <0.01%. [1][2][3] Patients are mostly asymptomatic, and the abnormality is often an incidental finding during imaging performed as the result of other cerebrovascular events. Rarely, they can be discovered during cervical ultrasound imaging. 1,2,4-6 We report the case of a 64-year-old man with agenesis of the left ICA who was treated with carotid endarterectomy (CEA) of the right ICA for an asymptomatic stenosis of 70% with a type III ulcerated plaque. The patient consented to publication of this report. CASE REPORTAn asymptomatic 64-year-old man was referred to the vascular surgery department on the basis of right ICA stenosis of 70% found during thyroid gland ultrasound screening. Stenosis of the left ICA was characterized as preocclusive, and the left common carotid artery (CCA) was characterized as hypoplastic. The left vertebral artery was oversized, and flow was significantly higher than in the left CCA.The patient's medical history revealed familial hypercholesterolemia and hypothyroidism. He was taking oral levothyroxine therapy (85 mg once daily) and acetylsalicylic acid (100 mg once daily) but could not tolerate statin therapy. Initial laboratory results were within normal reference ranges, accompanied by a normal chest X-ray and a normal electrocardiogram. A previous cerebral computed tomography scan was normal.Color duplex imaging of the carotid arteries was repeated by an affiliated specialist, and the initial finding of right ICA stenosis of 70% was confirmed, with an ICA peak systolic velocity of 230 cm/s and a ICA-to-CCA peak systolic velocity ratio of 4. The atherosclerotic plaque was characterized as type III (grey scale median ¼ 40), and a significant ulcerated area was noticed (Fig 1). Left ICA agenesis was diagnosed. The left CCA was hypoplastic, and the left vertebral artery was significantly dilated. Computed tomography angiography (CTA) confirmed all latter color duplex findings and demonstrated complete absence of the cervical, petrous, and cavernous left ICA (Fig 2).CEA of the right ICA under general anesthesia was performed with selective use of a Pruitt-Inahara Carotid shunt (LeMaitre Vascular Inc, Bu...