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Primary Mechanism of Stroke Reduction in Transcarotid Artery Revascularization is Dynamic Flow Reversal

Isaac N Naazie, Gregory A Magee, Asma Mathlouthi, Nadin Elsayed, Hanaa Dakour-Aridi, Mahmoud B Malas
Journal of Vascular Surgery 2020 December 1

OBJECTIVE: Recent studies have suggested that the low risk of stroke and death associated with TransCarotid Artery Revascularization (TCAR) is partially attributable to a robust dynamic flow reversal system as well as the avoidance of the atherosclerotic aortic arch during the stenting procedure. However, the benefit of flow reversal compared to distal embolic protection (DEP) in reducing stroke or death in transcarotid revascularization has not been studied.

METHODS: All patients undergoing carotid artery stenting via the transcarotid route with either dynamic flow reversal (TCAR) or DEP (TCAS_DEP) in the Vascular Quality Initiative from September 2016 to November 2019 were analyzed. Both multivariable logistic regression and nearest neighbor propensity score matched analysis were performed to explore differences in outcomes between the two procedures. Differences in outcomes were tested with McNemar test. The primary outcome was in-hospital stroke or death. Secondary outcomes were stroke, death, myocardial infarction (MI), and stroke, death or MI. A secondary analysis was preformed comparing transcarotid stenting with DEP vs transfemoral carotid stenting with DEP to evaluate the impact of crossing the aortic arch.

RESULTS: A total of 8,426 patients were identified (TCAS_DEP: 287; 3.4%). TCAR was associated with a lower risk of in-hospital stroke/death (1.6% vs 5.2%; OR: 0.35 [95% CI: 0.20-0.64]; P=0.001), stroke (1.4% vs 4.2%; OR: 0.37 [95% CI: 0.20-0.68]; P=0.002), and stroke/death/MI (2.0% vs 5.2%; OR: 0.41 [95% CI: 0.23-0.71]; P=0.001) compared to TCAS_DEP. Among the 274 pairs of patients identified with propensity score matching, TCAR was associated with a lower risk of stroke/death (1.1% vs 4.7%; RR: 0.23 [95% CI 0.06-0.81]; P=0.021) and stroke (0.4% vs 4.0%; RR: 0.09 [95% CI 0.01-0.70]; P=0.006) compared to TCAS_DEP but no differences in stroke/death/MI (1.8 vs 4.7%; , RR: 0.38 [95% CI: 0.15-1.02]; P=0.077). The secondary analysis found that there was no difference in stroke between TCAS_DEP and transfemoral carotid stenting with DEP (4.9% vs 3.7%, RR: 1.3 [95% CI: 0.36-1.63]; P=0.65).

CONCLUSIONS: Compared with TCAS_DEP, TCAR was associated with a lower risk of perioperative stroke or death and stroke. This implies dynamic flow reversal may be a better neuroprotection system than distal embolic filter in reducing the perioperative risk of stroke. Avoiding the aortic arch did not confer any reduction in stroke rate. This study serves to separate the clinical benefit of dynamic flow reversal from that of avoiding the aortic arch in TCAR.

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