Results associated with the health system-wide adoption of transcarotid revascularization

Husman, Regina; Tanaka, Akiko; Harlin, Stuart A.; Martin, Gordon H.; Saqib, Naveed U.; Keyhani, Arash; Keyhani, Kourosh; Wang, S. Keisin

doi:10.1016/j.jvs.2022.04.028

Cited by 3 publications

(6 citation statements)

References 26 publications

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“…Specific to the carotid module, 30-day results are more limited compared to the in-hospital data, which affected our methodology. Although most complications occur during the index hospitalization, we have previously noted that up to one-third of perioperative stroke and deaths occur from discharge to the 30-day postprocedure timepoint 5,6,28 . Other limitations include the lack of data on platelet inhibitor resistance, as discussed previously.…”

Section: Discussionmentioning

confidence: 98%

“…3,4 Thus far, in large institutional and national database studies, TCAR has been associated with equivalent stroke/death rates compared with CEA and superior results compared with TF-CAS. [5][6][7][8] Current SVS guidelines recommend dual antiplatelets in the perioperative period after carotid artery stenting (CAS). 2 However, this recommendation is largely based on results derived from the coronary literature and much lesser extent, the TF-CAS experience.…”

mentioning

confidence: 99%

“…In this way, the target lesion and the plaque-laden aortic arch are avoided entirely or instrumented with neuroprotection 3,4 . Thus far, in large institutional and national database studies, TCAR has been associated with equivalent stroke/death rates compared with CEA and superior results compared with TF-CAS 5–8 …”

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confidence: 99%

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Dual Antiplatelet Alternatives are Associated With Increased Stroke and Death After Transcarotid Revascularization

et al. 2022

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Objective: To define the risks associated with the replacement of dual antiplatelets for alternate medication regimens. Background: Patients undergoing transcarotid artery revascularization (TCAR) for atherosclerotic disease in the Vascular Quality Initiative database from September 2016 to June 2022 were included. In all, 29,802 TCAR procedures were captured between 2016 and 2022, consisting of 24,651 (82.7%) maintained on dual antiplatelet therapy (DAPT) and 5151 (17.3%) on alternative regimens. Methods: Patients maintained on DAPT were compared with those on alternative regimens consisting of any combination of single antiplatelet monotherapy and/or anticoagulation. Results: On univariable analysis, patients on alternative medications were more likely to experience in-hospital death, ipsilateral stroke, any stroke, and transient ischemic attacks compared with patients in the DAPT group. The mortality rate was higher at 1 year in the alternative cohort (4.7% vs 7.0%, P<0.01). The use of alternate medication regimens was associated with increased odds of stroke and the composite outcome of in-hospital stroke/death compared with DAPT. There was also a significant association between alternative medication use and increased odds of in-hospital transient ischemic attack, immediate stent occlusion, and return to the operating room. At 1 year, there was no significant difference in the incidence of stroke between the 2 groups. However, the use of alternate regimens was associated with higher 1-year of mortality after multivariable adjustment. Conclusions: Patients not maintained on DAPT after TCAR experienced an increased risk of stroke and death in the perioperative and follow-up periods. Increased surgeon vigilance is required to ensure compliance with dual antiplatelets as recommended.

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Section: Discussionmentioning

confidence: 98%

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confidence: 99%

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Dual Antiplatelet Alternatives are Associated With Increased Stroke and Death After Transcarotid Revascularization

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“…3 We have previously described our institutional practice patterns with respect to perioperative care and follow-up in detail. 8-11…”

Section: Methodsmentioning

confidence: 99%

“…3 We have previously described our institutional practice patterns with respect to perioperative care and follow-up in detail. [8][9][10][11] Univariate statistical testing was performed using JMP software version 16 (SAS Institute Inc, Cary, NC). Continuous variables were reported with a mean ± standard deviation or median ± interquartile range dependent of the distribution.…”

Section: Methodsmentioning

confidence: 99%

Transcarotid Revascularization Results in Patients Over 70 Years of Age

Dias

Fajardo

Martin

et al. 2022

Vasc Endovascular Surg

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Objective Carotid endarterectomy is associated with fewer procedure-related strokes than transfemoral carotid artery stenting in older populations, based on the results from previous quality randomized controlled studies. Transcarotid artery revascularization (TCAR) is a hybrid procedure completed in the setting of cerebral flow reversal to deploy a stent, making it an appealing choice for older patients. This study was completed to elicit any age-related differences in outcomes after undergoing TCAR in patients 70 years of age and older. Methods A retrospective review was completed of a dual institutional database between December 2015 and April 2022 to capture demographics, comorbidities, and perioperative results. The geriatric cohort was defined at a cutoff of 70 years. Univariate statistical testing between groups were completed with Student’s T-test or Fisher’s exact test at an α of .05 for continuous and categorical variables, respectively. Results 851 procedures were captured for statistical analysis. With age cutoff of 70 years, we generated 567 geriatric (78.4 ± 5.7 years) and 284 young (63.2 ± 5.7 years) patients. The older patients tended to have more baseline illness, as measured by a higher rate Charlson Comorbidity Index (4.4 ± 2.2 vs 6.0 ± 2.1, P < .01). Younger patients tended to be actively smoking (42.3% vs 17.6%, P < .01). Intraoperative variables were grossly similar by age, including blood loss (43.0 ± 45.0 vs 45.7 ± 50.3 mLs, P = .45), reverse flow time (9.0 ± 7.4 vs 9.0 ± 6.7 mins, P = .98), and technical success (98.9% vs 98.6%, P = .76). While we observed an increased rate of stroke in the older patients, this did not reach statistical significance (1.4% vs 2.6%, P = .33). There were no differences between age groups with respect to myocardial infarction (0% vs .5%, P = .55) and death (1.1% vs 1.1%, P > .99) in the 30-day perioperative period. Conclusion We found that TCAR was not associated with age-related increases in adverse outcomes and can be considered a viable option when treating carotid artery stenosis in patients older than 70 years of age.

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Propensity-score-matched analysis of dual antiplatelet treatment and alternative antiplatelet regimens after transcarotid revascularizations

Dakour-Aridi

Motaganahalli

Fajardo

et al. 2023

Journal of Vascular Surgery

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Results associated with the health system-wide adoption of transcarotid revascularization

Cited by 3 publications

References 26 publications

Dual Antiplatelet Alternatives are Associated With Increased Stroke and Death After Transcarotid Revascularization

Dual Antiplatelet Alternatives are Associated With Increased Stroke and Death After Transcarotid Revascularization

Transcarotid Revascularization Results in Patients Over 70 Years of Age

Propensity-score-matched analysis of dual antiplatelet treatment and alternative antiplatelet regimens after transcarotid revascularizations

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