Transcarotid Artery Revascularization: A Novel Approach to Tackling High-Risk Carotid Lesions

Purpose: Transcarotid artery revascularization (TCAR) using the ENROUTE Neuroprotection System (Silk Road Medical Inc, Sunnyvale, CA) is a novel approach toward carotid artery stenting (CAS). This minimally invasive approach uses intraprocedure high-rate flow reversal NPS and is designed for CAS in patients who are deemed too high risk for carotid artery endarterectomy (CEA). The system has shown superior stroke and death outcomes compared with prior registry results from both CEA and transfemoral CAS. The purpose of this study is to review of both short- and long-term outcomes in patients who underwent TCAR and so to underscore high-risk anatomical lesion that are made easier with TCAR over a transfemoral approach.

Materials and Methods: We performed an institutional review board–approved single-center retrospective review of patients who underwent TCAR procedures between August 2017 and September 2018. All interventions were performed in patients deemed at high risk for complications from CEA, symptomatic patients with 50% stenosis, or asymptomatic patients with 70% stenosis. A hybrid OR was used for all procedures and co-staffed with a vascular surgeon and an interventional radiologist. Patients were followed in clinic at 1, 6, and 12 months postprocedure. Demographic data, anatomical considerations, and complications were reviewed.

Results: Twenty-nine TCARs were performed on 28 patients, with an age range of 59 to 85 years (M:F, 19:9). Technical success rate was 100%, with no acute device, technical, or access site complications. All lesions were successfully crossed, and 30 stents were deployed (one lesion required two overlapping stents). One patient underwent bilateral TCAR on separate occasions, and another patient underwent concurrent TCAR and TVAR. Fifteen anatomically challenging lesions were identified: 7 high carotid bifurcations, 4 stenoses at or above C2 level, 3 long-segment lesions, and 1 tortuous ICA. One adverse outcome was reported within 30 days (ipsilateral intraparenchymal hemorrhage), with an overall adverse-free event rate of 97%. No myocardial infarction or death occurred. All patients remained neurologically symptom free at their follow-up, and the average time to follow-up was 151 days.

Conclusions: TCAR is a safe and novel approach to CAS using cerebral flow reversal as a means of providing neuroprotection. It can be used to tackle lesions deemed too high risk for TF-CAS or CEA. This procedure requires a high technical skillset and is best performed using a multidisciplinary team with a vascular surgeon and an interventional radiologist.