Postoperative Bleeding Complications are Common among Patients Undergoing Transcarotid Artery Revascularization

Current practice guidelines recommend dual antiplatelet therapy for at least 30 days postoperatively after transcarotid artery revascularization (TCAR) to promote stent patency. However, many patients are already taking other antithrombotic medications. The optimal pharmacologic regimen in this patient population remains unclear, especially as it pertains to postoperative bleeding complications.

All TCAR procedures performed at a large academic medical center from January 1, 2017, to April 30, 2023, were identified via current procedural terminology codes and retrospectively reviewed via electronic medical records. Data were collected on patient demographics, procedural details, postoperative complications, and antithrombotic regimen. Bleeding complications were categorized as surgical and nonsurgical, which included any bleeding diatheses that were not related to the neck incision, such as epistaxis, hematuria, melena, or noncervical hematoma.

A total of 116 TCAR procedures were performed. The 30-day incidence of bleeding complications was 12.1% (n = 14), which included 8 (6.9%) symptomatic neck hematomas and 6 (5.2%) nonsurgical site bleeding complications. Aside from patient age (median 72 years [66-79] vs. 79 years [70.5-88], P = 0.03), demographics, medical comorbidities, surgical indication, risk-related indication for TCAR, and inpatient/outpatient status were similar between patients who experienced bleeding versus no bleeding complications. Patients who developed bleeding complications experienced higher 30-day hospital readmission (42.9% vs. 9.8%, P < 0.001) and reintervention rates (21.4% vs. 2.0%, P < 0.001) and trended toward longer postoperative length of stay (1.5 days [1-3] vs. 1 [1-2] days, P = 0.07). Reasons for readmission (n = 16) included: epistaxis (1), hematuria (1), headache and melena (1), melena and myocardial infarction (1), fall (1), headache (1), dyspnea (5), delirium (1), diarrhea (1), atrial fibrillation (1), and neck hematoma (1); 1 patient did not have a readmission reason documented. Reinterventions (n = 6) included neck hematoma evacuation (2), epistaxis cauterization (1), emergent cricothyroidotomy (1), and repeat carotid stenting (1). The management of antithrombotic medications during bleeding events were highly variable among providers (11 patients with nothing held, 1 apixaban held, 1 aspirin held, 1 clopidogrel held); however, no patients suffered carotid stent thrombosis.

Bleeding complications are common within 30 days of TCAR and frequently result in unplanned hospital readmission and reintervention. There is significant provider-level variability in management of antithrombotic medications during these events. These data highlight need for evidence-based guidelines for the optimal pharmacologic strategy for patients post-TCAR who develop bleeding complications.