Initial Experience with Transcarotid Artery Revascularization (TCAR) Demonstrates its Safety and Efficacy in Elderly High-Risk Patients
Ahmed K. Ghamraoui, DO, MS, Victoria Konovalova, DO, Joseph J. Ricotta, MD, MS, FACS
Delray Medical Center, Delray Beach, FL
OBJECTIVES:
Carotid revascularization, both endarterectomy (CEA) and stenting (CAS), is associated with an increased risk of adverse outcomes in patients >80 years of age. Transcarotid artery revascularization (TCAR) is a novel technique that combines surgical principles of neuroprotection with less invasive endovascular techniques to treat severe carotid stenosis. The first TCAR procedure in South Florida was performed successfully at our institution in May 2018 on a symptomatic 89-year-old female. Since that time, we have had success treating a number of high-risk elderly patients. We present our initial experience with TCAR in patients > 80 years of age.
METHODS:
The clinical data of patients undergoing TCAR for symptomatic ( >50%) or asymptomatic (>80%) carotid stenosis at our institution between May 31, 2018 and September 14, 2018 were prospectively collected. Analysis included presence or absence of symptoms, age, peri-procedural and 30-day stroke, myocardial infarction, cranial nerve injury, and mortality. In addition, type of anesthesia, procedure times, clamp/flow reversal times, fluoroscopy times, and postoperative length of hospital stay (LOS) were also reviewed.
RESULTS:
Sixteen TCAR procedures have been performed, of which 12 were on patients over 80 years old with a mean age of 85.8 years. Eight were performed for symptomatic disease, with mean carotid stenosis of 88%, and four were for asymptomatic disease, with a mean carotid stenosis of 90%. The mean procedural time was 57 minutes, with a mean clamp/flow-reversal time of 5 minutes, and mean fluoroscopy time of 5.5 minutes. General anesthesia was performed in 8 patients and local anesthesia with sedation in 4 patients. Technical success was achieved in all cases, with no mortalities, no periprocedural or 30-day strokes, no myocardial infarctions, and no cranial nerve injuries. Average postoperative LOS was 2.6 days, 2.5 days for those admitted as outpatients and 2.7 days for those who were already inpatients prior to procedure. This was independent of symptom status.
CONCLUSIONS:
Our initial experience with TCAR demonstrates that it can be performed successfully and safely in both symptomatic and asymptomatic high-risk patients older than 80 years of age. Procedure and clamp times are short, as well as LOS. TCAR may represent a safe and effective alternative to CEA and CAS for high-risk elderly patients.
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