Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy

Abstract

Background and Purpose: Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke. The optimal procedural modality for this indication has yet to be determined. Here, we evaluate the in-hospital outcomes of transcarotid artery revascularization (TCAR), redo-CEA, and transfemoral carotid artery stenting (TFCAS) in a large contemporary cohort of patients who underwent treatment for restenosis after CEA. Methods: We performed a retrospective analysis of all patients in the vascular quality initiative database who underwent TCAR, redo-CEA, or TFCAS after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral CAS were excluded from this analysis. In-hospital outcomes following TCAR versus CEA and TCAR versus TFCAS were evaluated using multivariate logistic regression analysis. Results: A total of 4425 patients were available for this analysis. There were 963 (21.8%) redo-CEA, 1786 (40.4%) TFCAS, and 1676 (37.9%) TCAR. TCAR was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% CI, 0.24–0.70], P =0.021), stroke (OR, 0.46 [95% CI, 0.23–0.93], P =0.03), myocardial infarction (MI; OR, 0.32 [95% CI, 0.14–0.73], P =0.007), stroke/transient ischemic attack (OR, 0.42 [95% CI, 0.24–0.74], P =0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24–0.70], P =0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the 2 groups (OR, 0.99 [95% CI, 0.28–3.5], P =0.995). TCAR was also associated with lower odds of stroke/transient ischemic attack (OR, 0.37 [95% CI, 0.18–0.74], P =0.005) when compared with TFCAS. There was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI between TCAR and TFCAS. Conclusions: TCAR was associated with significantly lower odds of in-hospital stroke, MI, stroke/transient ischemic attack, stroke/death, and stroke/death/MI when compared with redo-CEA and lower odds of in-hospital stroke/transient ischemic attack when compared with TFCAS. Additional long-term studies are warranted to establish the role of TCAR for the treatment of restenosis after CEA.

What Is the Role of Transcarotid Artery Revascularization?

“…Analysis of 4425 patients with restenosis after CEA in VQI demonstrated that TCAR was associated with lower odds of in-hospital stroke/death (OR ¼ 0.41 [95% CI: 0.24-0.70]; P ¼ .021), and MI (OR ¼ 0.32 [95% CI: 0.14-0.73]; P ¼ .007), when compared with redo-CEA. TCAR was also associated with lower odds of stroke/TIA (OR ¼ 0.37 [95% CI: 0.18-0.74]; P ¼ .005) when compared with TFCAS [96]. In another national study from our team, CEA and CAS following prior CAS were compared.…”

Medical and Surgical Management of Symptomatic and Asymptomatic Carotid Artery Stenosis: A Comprehensive Literature Review

“…TCAR is associated with a significantly lower risk of in-hospital stroke/death, stroke, stroke/TIA, MI, and stroke/death/MI compared to redo-CEA. In addition, TCAR carries a lower risk of in-hospital stroke/TIA compared to TF-CAS [ 61 ]. Risk factors, such as previous stroke, ischemic heart disease (IHD), and the degree of stenosis, have been found to be associated with postoperative complications.…”

Transcarotid versus transfemoral access for cerebrovascular intervention: protocol for a systematic review and meta-analysis

“…21 It has been shown in numerous clinical trials that TCA has a lower stroke rate. [22][23][24][25] Despite this, the benefits and risks of TCA compared with TFA are unclear, and there is no guideline that assists clinicians in making the right choice. The purpose of this study is to compare the safety and efficacy of TCA versus TFA for cerebrovascular interventions.…”

“…As compared with TFA, TCA eliminates the need to traverse the aortic arch, reduces the production of debris and the risk of atheroembolisation, and takes a shorter procedure period 21. It has been shown in numerous clinical trials that TCA has a lower stroke rate 22–25. Despite this, the benefits and risks of TCA compared with TFA are unclear, and there is no guideline that assists clinicians in making the right choice.…”