Transcarotid Artery Revascularization as a New Modality of Treatment for Carotid Stenosis

Carotid artery stenosis is a significant cause of ischemic stroke, and studies have shown that transfemoral carotid artery stenting is associated with a higher perioperative stroke risk than open endarterectomy. Transcarotid artery revascularization (TCAR) is a novel technique in carotid stenting via direct transcervical carotid access without the risk of arch manipulation, offers a smaller wound compared with endarterectomy, and employs flow reversal to decrease the risk of antegrade embolic stroke. Contemporary evidence on the safety and efficacy of TCAR is reviewed.

A systematic literature review on TCAR from January 2009 to August 2019 was performed in PubMed and EMBASE databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Clinical studies on TCAR with flow reversal with clinical outcomes of stroke, myocardial infarction (MI), and death were included.

Initial search of the literature yielded 161 articles, of which 8 studies were included comprising of 5 single-arm studies and 3 comparative studies. Studies demonstrated high technical success rates of TCAR from 90.6% to 100%, with low perioperative stroke, MI, and mortality rates of 0 to 4%, 0 to 0.7% and 0 to 2.7%, respectively. TCAR was significantly associated with a lower in-hospital stroke/transient ischemic attack rate when compared to transfemoral carotid stenting. There was no significant difference in perioperative stroke/MI/death when compared to endarterectomy although TCAR had a significantly lower risk of cranial nerve injury.

TCAR with flow reversal is a promising treatment option for carotid occlusive disease. Clinical trials are currently underway to provide a better report on outcomes of TCAR and for further comparison between TCAR and carotid endarterectomy.