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Results of carotid artery stenting with transcervical access
George S Sfyroeras1, Konstantinos G Moulakakis, Fotis Markatis
1Department of Vascular Surgery, Attikon University Hospital, Athens, Greece.
Insights
Transcervical carotid artery stenting (CAS) offers a safe alternative to femoral access for patients with challenging anatomy. This approach demonstrates a low incidence of stroke and complications, making it a viable option for carotid artery interventions.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurology
Background:
- Femoral access for carotid artery stenting (CAS) can be limited by patient anatomy.
- Embolic events during CAS often occur during aortic arch catheterization.
- Transcervical access presents an alternative route for CAS.
Purpose of the Study:
- To evaluate the safety and efficacy of transcervical access for CAS.
- To compare outcomes of direct CAS versus CAS with reversed flow via transcervical access.
- To assess complication rates associated with the transcervical approach for CAS.
Main Methods:
- Systematic literature review of PubMed.
- Inclusion of 12 studies reporting on 739 CAS procedures.
- Analysis of technical success, conversion to open repair, and complication rates.
Main Results:
- Technical success rate of 96.3% for transcervical CAS.
- Low incidence of stroke (1.1%), myocardial infarction (0.14%), and death (0.41%).
- Local complications, including hematomas and laryngeal palsy, occurred in 2.9% of cases.
Conclusions:
- Transcervical CAS is a safe and effective alternative to femoral access.
- The procedure is well-tolerated, even in patients with unfavorable anatomy.
- Low rates of stroke and complications support its use in select patient populations.
Objective:
Carotid artery stenting (CAS) is usually performed with femoral access; however, this access may be impeded by anatomic limitations. Moreover, many embolic events happen during aortic arch catheterization. To overcome these problems, transcervical access to the carotid artery can be used as an alternative approach for CAS.
Methods:
An electronic search of the literature using PubMed was performed. All studies reporting the results of CAS using the transcervical approach were retrieved and analyzed.
Results:
The analysis included 12 studies reporting the results of 739 CAS procedures performed in 722 patients (mean age, 75.5 years). Of 533 lesions reported, 235 (44%) were symptomatic, with no data regarding symptomatic status available for 206 lesions. Two techniques were used: direct CAS with transcervical access (filter protected or unprotected) in 250 patients and CAS with transcervical access under reversed flow (with arteriovenous shunt in most cases) in 489 patients. Local anesthesia was used in 464 of 739 procedures (63%), and the remaining were performed under general anesthesia or cervical block. Technical success was 96.3% for 579 procedures with available data (558 successful procedures and 21 failures: inability to cross the lesion, 10; dissection, 5; failure of predilatation, 1; stent thrombosis, 1; patient agitation, 1; and no data, 3). The incidence of conversion to open repair was 3.0% (20 of 579 procedures: 18 carotid endarterectomies and two common carotid-internal carotid bypass grafts). Stroke occurred in eight patients (two fatal) and a fatal myocardial infarction in one patient. The incidence of stroke, myocardial infarction, and death was 1.1%, 0.14%, and 0.41%, respectively. The incidence of stroke was 1.2% (3 of 250) in direct CAS with transcervical access and 1.02% (5 of 489) in CAS under reversed flow (P > .05). Transient ischemic attack occurred in 20 patients (2.7%). Local complications were encountered in 17 of 579 CAS (2.9%), comprising 15 hematomas and two patients with transient laryngeal palsy.
Conclusions:
CAS with the transcervical approach is a safe procedure with low incidence of stroke and complications. It can be used as an alternative to femoral access in patients with unfavorable aortoiliac or aortic arch anatomy.