Outcomes of Transcarotid Artery Revascularization (TCAR) in Octogenarians and Older

Carotid revascularization, both endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS), are associated with an increased risk of adverse outcomes in patients aged ≥80 years. Transcarotid artery revascularization (TCAR) is a technique that combines surgical principles of neuroprotection with less invasive endovascular techniques to treat severe carotid stenosis. Data from a recent registry study comparing TCAR with that of CEA and TFCAS demonstrated no significant difference in outcomes between TCAR and CEA in patients aged ≥80 years, and a significant reduction in stroke and composite outcomes between TCAR and TFCAS in patients aged ≥80 years. To add to these studies, a more in-depth analysis of demographic, procedural, and outcome factors is warranted for elderly patients aged ≥80 years undergoing TCAR. At our center, with a large volume of elderly patients based on local demographics, we expect there will be no significant effect of age on outcome measures between patients aged <80 years and those aged ≥80 years.

Data were collected retrospectively for patients undergoing TCAR for symptomatic (≥50%) or asymptomatic (≥80%) extracranial carotid artery stenosis. Primary endpoints were the incidence of ipsilateral cerebrovascular ischemic event (stroke or transient ischemic attack), myocardial infarction (MI), cranial nerve injury, and death through 30 days after the procedure. Secondary endpoints were postoperative length of hospital stay (LOS), procedure time, carotid artery clamp/flow reversal time, and fluoroscopy time. Subgroup analyses were performed to examine the effect of inpatient/outpatient status, carotid symptomatology, and type of anesthesia on secondary outcomes.

Ninety-seven TCAR procedures were performed at our institution during the study period, of which 43 (44%) were on patients aged ≥80 years. Technical success was achieved in all cases, with no incidence of cerebrovascular ischemic event, MI, cranial nerve injury, or mortality through 30 days after procedure. In patients aged ≥80 years, the mean procedure time was 47 ± 12 min, clamp/flow reversal time was 4.7 ± 1.1 min, fluoroscopy time was 4.1 ± 1.6 min, and median LOS was 2.0 ± 1.0 days. Procedure time, clamp/flow reversal time, and fluoroscopy time were not significantly different between the age groups. However, there was a significant difference in the LOS, with patients aged <80 years demonstrating a median LOS of 1.0 ± 0.0 days (P = <0.001).

Our experience with TCAR confirms that it can be performed successfully in both symptomatic and asymptomatic high-risk elderly patients, with our series finding no incidence of perioperative cerebral ischemic event, MI, or death.