Initial Tcar Experience In A Community Practice Setting
Ashlee Vinyard, MD1, Paul Dhot, BS1, Yahya Daoud, MS1, John J. Squiers, MD2, Dennis Gable, MD2, William P. Shutze, Sr., MD2.
1Texas Vascular Associates, Plano, TX, USA, 2The Heart Hospital Baylor Plano, Plano, TX, USA.
Background
While Trans-carotid arterial revascularization (TCAR) has shown excellent outcomes there is an absence of robust reported experience from the community setting. We evaluated our TCAR experience to evaluate this procedure in a community-based population results undergoing TCAR.
Methods
We performed a retrospective review of all patients undergoing attempted TCAR from 12/13/2016-2/20/2020 by surgeons in our community-based practice. All available patient characteristics, pre-treatment disease, high risk criteria, treatment, procedural detail, and outcome data (up to one month) TCAR were collected. Association between 30 days MACE and continuous variables were evaluated using logistic regression, and Fisher's exact test if applicable and Pearson's chi-squared test were used for categorical variables
Results
TCAR was attempted in 281 patients with two conversions leaving 279 patients. Patient characteristics/preoperative imaging are reported in Table 1. 141 (50.5%) patients were asymptomatic and 138 (49.5%) were asymptomatic High risk anatomic factors were: Age > 75 years (135), high lesion (103), hostile neck (50), post CEA restenosis (32), bilateral stenosis requiring treatment (14), spine immobility (12), laryngeal nerve palsy (10), tandem stenosis (5), and contralateral occlusion (1). Clinical high-risk factors were ESRD (19), uncontrollable DM (19), COPD (15), MI within 6 weeks (2), CHF class III/IV (1), multivessel CAD (1), angina (1), and need for open heart surgery (1). Perioperative medications/procedure details are described in Table 2. There were 2 access site complications (dissections), but no cranial nerve injuries or hyperperfusion events. 30 days MACE was 3 strokes/TIAs (1.1%), 2 myocardial infarctions (0.7%) and 2 deaths (0.7%). Diabetes and local anesthesia were risk factors for MACE. Preoperative imaging with ultrasound only was found to be safe without increasing risk of MACE.
Conclusion
This report demonstrates that a TCAR program can be successfully launched in a community setting with results comparable to the TCAR trials and large registries. In our experience DM increases the risk of MACE but duplex ultrasound was found to be safe for preoperative imaging and case planning.
| Table 1. Patient Characteristics and Perioperative Imaging | |||||
| < 30 Day MACE | Total (279) | ||||
| No (272) | Yes (7) | P-Value | |||
| Statistics | Statistics | Statistics | 95% CI | ||
| Patient Age: Mean ± SD | 73.86 ± 8.61 | 77.88 ± 3.65 | 0.2191 | 73.96 ± 8.54 | (72.96 - 74.97) |
| Median (Q1, Q3) | 74.0 (69.3, 80.1) | 77.8 (76.2, 80.1) | 74.4 (69.4, 80.1) | ||
| Gender (Female) | 90 (33.09) | 1 (14.29) | 0.4331 | 91 (32.62) | (27.12 - 38.12) |
| Comorbidities | |||||
| Hypertension | 207 (76.10) | 6 (85.71) | 1.0000 | 213 (76.34) | (71.35 - 81.33) |
| HLD | 159 (58.46) | 3 (42.86) | 0.4579 | 162 (58.06) | (52.27 - 63.85) |
| DM | 105 (38.60) | 0 (0.00) | 0.0475 | 105 (37.63) | (31.95 - 43.31) |
| CAD | 79 (29.04) | 3 (42.86) | 0.4229 | 82 (29.39) | (24.04 - 34.74) |
| PVD | 32 (11.76) | 0 (0.00) | 1.0000 | 32 (11.47) | (7.73 - 15.21) |
| ESRD | 19 (6.99) | 0 (0.00) | 1.0000 | 19 (6.81) | (3.85 - 9.77) |
| Tobacco Exposure | 171 (62.87) | 4 (57.14) | 0.7143 | 175 (62.72) | (57.05 - 68.39) |
| Preoperative Imaging | 0.2874 | ||||
| CT | 152 (55.88) | 6 (85.71) | 158 (56.63) | (50.81 - 62.45) | |
| Ultrasound | 113 (41.54) | 1 (14.29) | 114 (40.86) | (35.09 - 46.63) | |
| MRI/MRA | 7 (2.57) | 0 (0.00) | 7 (2.51) | (0.67 - 4.35) | |
| Q1 = Lower QuartileQ3 = Upper Quartile | |||||
| Table 2. Perioperative Medications and Procedure Details | ||||||
| < 30 Day MACE | Total (279) | |||||
| No (272) | Yes (7) | P-Value | ||||
| Statistics | Statistics | Statistics | 95% CI | |||
| Admission ASA | 228 (83.82) | 7 (100.00) | 0.6012 | 235 (84.23) | (79.95 - 88.51) | |
| Admission P2Y Inhibitor | 211 (77.57) | 6 (85.71) | 1.0000 | 217 (77.78) | (72.90 - 82.66) | |
| Admission Statin | 194 (71.32) | 7 (100.00) | 0.1961 | 201 (72.04) | (66.77 - 77.31) | |
| Anesthesia | 0.0311 | |||||
| General | 257 (94.49) | 5 (71.43) | 262 (93.91) | (91.10 - 96.72) | ||
| Local | 14 (5.15) | 2 (28.57) | 16 (5.73) | (3.00 - 8.46) | ||
| Local + Minor Conscious Sedation | 1 (0.37) | 0 (0.00) | 1 (0.36) | (0.00 - 1.06) | ||
| Pre-Dilation | 183 (67.28) | 6 (85.71) | 0.4347 | 189 (67.74) | (62.25 - 73.23) | |
| Post-Dilation | 162 (59.56) | 3 (42.86) | 0.4490 | 165 (59.14) | (53.37 - 64.91) | |
| Additional Stent(s) | 26 (9.56) | 0 (0.00) | 1.0000 | 26 (9.32) | (5.91 - 12.73) | |
| Procedure Time (minutes): Mean ± SD | 50.54 ± 14.27 | 47.43 ± 7.83 | 0.5569 | 50.46 ± 14.15 | (48.79 - 52.13) | |
| Median (Q1, Q3) | 48.0 (43, 55) | 45.0 (45.0, 45.0) | 48.0 (43, 55) | |||
| Reverse Flow Time (minutes): Mean ± SD | 9.52 ± 5.69 | 8.00 ± 2.77 | 0.4768 | 9.48 ± 5.63 | (8.82 - 10.15) | |
| Median (Q1, Q3) | 8.0 (6.0, 11.0) | 7.0 (5.0, 11.0) | 8.0 (6.0, 11.0) | |||
| Fluoro Time (minutes): Mean ± SD | 4.50 ± 2.54 | 3.79 ± 1.52 | 0.4880 | 4.48 ± 2.52 | (4.18 - 4.78) | |
| Median (Q1, Q3) | 4.0 (3.0, 5.1) | 3.5 (2.5, 5.3) | 4.0 (3.0, 5.1) | |||
| Contrast Used (ml): Mean ± SD | 36.80 ± 17.52 | 36.43 ± 14.06 | 0.9551 | 36.79 ± 17.42 | (34.73 - 38.85) | |
| Median (Q1, Q3) | 30.0 (25, 45) | 35.0 (20.0, 50.0) | 30.0 (25, 45) | |||
| Post-op LOS (days): Mean ± SD | 1.70 ± 1.21 | 3.00 ± 2.52 | 0.0144 | 1.73 ± 1.27 | (1.58 - 1.88) | |
| Median (Q1, Q3) | 1.0 (1.0, 2.0) | 2.0 (1.0, 6.0) | 1.0 (1.0, 2.0) | |||
| Discharge ASA | 255 (93.75) | 7 (100.00) | 1.0000 | 262 (93.91) | (91.10 - 96.72) | |
| Discharge P2Y Inhibitor | 234 (86.03) | 6 (85.71) | 1.0000 | 240 (86.02) | (81.95 - 90.09) | |
| Q1 = Lower QuartileQ3 = Upper Quartile | ||||||
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