Transcarotid artery revascularization: innovative approaches in high-risk carotid artery stenosis_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

XIANG Yuwei , HU Huanrui ,  YANG Yi , HAN Maonan , LIU Yang , HUANG Bin , MA Yukui , ZHAO Jichun

Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding?author：

YANG Yi, Email: yangy@wchscu.cn

Keywords：

transcarotid artery revascularization; arotid artery stenosis; carotid endarterectomy; transfemoral carotid artery stenting

DOI：

10.7507/1007-9424.202510088

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Objective To evaluate the safety, efficacy, and advantages of transcarotid artery revascularization (TCAR) in patients with high-risk carotid artery stenosis. Methods The patient was a 76-year-old male with severe symptomatic stenosis of the right internal carotid artery, complicated by multiple high-risk factors (such as cardiac insufficiency, history of coronary stent implantation, aortic calcification). Given his unsuitability for carotid endarterectomy and the high perioperative risk associated with transfemoral carotid artery stenting, TCAR was performed. The procedure involved puncturing the common carotid artery via a small cervical incision to establish a temporary carotid-to-femoral venous reversed-flow pathway. Following balloon predilation, a stent was deployed, and the reversed-flow system was used to divert potential plaque debris outward, thereby reducing the risk of intraoperative cerebral embolism. Results The procedure was completed successfully. The operation time was approximately 70 min, the estimated blood loss was 20 mL. Postoperatively, the patient did not experience complications such as stroke, neurological deficit, or hyperperfusion syndrome. Although carotid sinus reflex-induced hypotension occurred, which stabilized after pharmacological management. The results of following-up at 3 months showed the stent was patent with no evidence of in-stent restenosis. Conclusions The findings of this case indicate that TCAR combines the cerebral protection advantages of carotid endarterectomy with the minimally invasive features of transfemoral carotid artery stenting. Its reversed-flow mechanism helps effectively prevent intraoperative embolism, offering a safe and viable revascularization option for patients with high-risk carotid artery stenosis.

1.	Fu J, Deng Y, Ma Y, et al. National and provincial-level prevalence and risk factors of carotid atherosclerosis in Chinese adults. JAMA Netw Open, 2024, 7(1): e2351225. doi: 10.1001/jamanetworkopen.023.512252.
2.	Howard DPJ, Gaziano L, Rothwell PM, et al. Risk of stroke in relation to degree of asymptomatic carotid stenosis: a population-based cohort study, systematic review, and meta-analysis. Lancet Neurol, 2021, 20(3): 193-202.
3.	Kakisis JD, Antonopoulos CN, Mantas G, et al. Cranial nerve injury after carotid endarterectomy: incidence, risk factors, and time trends. Eur J Vasc Endovasc Surg, 2017, 53(3): 320-335.
4.	Bonati LH, Jansen O, de Borst GJ, et al. Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol, 2022, 21(3): 273-283.
5.	Naylor R, Rantner B, Ancetti S, et al. Editor’s choice—European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease. Eur J Vasc Endovasc Surg, 2023, 65(1): 7-111.
6.	Paraskevas KI, Brown MM, Lal BK, et al. Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis. J Vasc Surg, 2024, 79(3): 695-703.
7.	Malas MB, Leal Lorenzo JI, Nejim B, et al. Analysis of the ROADSTER pivotal and extended-access cohorts shows excellent 1-year durability of transcarotid stenting with dynamic flow reversal. J Vasc Surg, 2019, 69(6): 1786-1796.
8.	Kashyap VS, So KL, Schneider PA, et al. One-year outcomes after transcarotid artery revascularization (TCAR) in the ROADSTER 2 trial. J Vasc Surg, 2022, 76(2): 466-473. e1. doi: 10.1016/j.jvs.2022.03.872.
9.	Wang J, Bai X, Wang T, et al. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis: a systematic review and meta-analysis. Stroke, 2022, 53(10): 3047-3054.
10.	Saratzis A, Naylor R. 30 day outcomes after carotid interventions: an updated meta-analysis of randomised controlled trials in asymptomatic patients. Eur J Vasc Endovasc Surg, 2022, 63(1): 157-158.
11.	Naazie IN, Cui CL, Osaghae I, et al. A systematic review and meta-analysis of transcarotid artery revascularization with dynamic flow reversal versus transfemoral carotid artery stenting and carotid endarterectomy. Ann Vasc Surg, 2020, 69: 426-436.
12.	Malas MB, Dakour-Aridi H, Kashyap VS, et al. Transcarotid revascularization with dynamic flow reversal versus carotid endarterectomy in the vascular quality initiative surveillance project. Ann Surg, 2022, 276(2): 398-403.
13.	Malas MB, Elsayed N, Naazie I, et al. Propensity score-matched analysis of 1-year outcomes of transcarotid revascularization with dynamic flow reversal, carotid endarterectomy, and transfemoral carotid artery stenting. J Vasc Surg, 2022, 75(1): 213-222.
14.	Wu H, Wang Z, Li M, et al. Outcomes of transcarotid artery revascularization: a systematic review. Interv Neuroradiol, 2024, 30(3): 396-403.
15.	Olesen ND, Frederiksen HJ, Storkholm JH, et al. Internal carotid artery blood flow is enhanced by elevating blood pressure during combined propofol-remifentanil and thoracic epidural anaesthesia: a randomised cross-over trial. Eur J Anaesthesiol, 2020, 37(6): 482-490.
16.	Lee D, Batista PM, McMackin KK, et al. Intraoperative blood pressure lability carries a higher risk of headache after carotid endarterectomy. J Vasc Surg, 2022, 75(2): 592-598.
17.	Kawamata T, Okada Y, Kawashima A, et al. Postcarotid endarterectomy cerebral hyperperfusion can be prevented by minimizing intraoperative cerebral ischemia and strict postoperative blood pressure control under continuous sedation. Neurosurgery, 2009, 64(3): 447-453.
18.	Yang X, Liu Z, Hu C, et al. Incidence and risk factors for hypotension after carotid artery stenting: systematic review and meta-analysis. Int J Stroke, 2024, 19(1): 40-49.
19.	G?k?al E, Niftaliyev E, Deniz ?, et al. Prolonged hypotension after carotid artery stenting: incidence, predictors and consequences. Acta Neurochir (Wien), 2017, 159(11): 2081-2087.
20.	Nanto M, Goto Y, Yamamoto H, et al. Complications and predictors of hypotension requiring vasopressor after carotid artery stenting. Neurol Med Chir (Tokyo), 2017, 57(3): 115-121.
21.	Dangas G, Laird JR, Satler LF, et al. Postprocedural hypotension after carotid artery stent placement: predictors and short- and long-term clinical outcomes. Radiology, 2000, 215(3): 677-683.

1. Fu J, Deng Y, Ma Y, et al. National and provincial-level prevalence and risk factors of carotid atherosclerosis in Chinese adults. JAMA Netw Open, 2024, 7(1): e2351225. doi: 10.1001/jamanetworkopen.023.512252.
2. Howard DPJ, Gaziano L, Rothwell PM, et al. Risk of stroke in relation to degree of asymptomatic carotid stenosis: a population-based cohort study, systematic review, and meta-analysis. Lancet Neurol, 2021, 20(3): 193-202.
3. Kakisis JD, Antonopoulos CN, Mantas G, et al. Cranial nerve injury after carotid endarterectomy: incidence, risk factors, and time trends. Eur J Vasc Endovasc Surg, 2017, 53(3): 320-335.
4. Bonati LH, Jansen O, de Borst GJ, et al. Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol, 2022, 21(3): 273-283.
5. Naylor R, Rantner B, Ancetti S, et al. Editor’s choice—European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease. Eur J Vasc Endovasc Surg, 2023, 65(1): 7-111.
6. Paraskevas KI, Brown MM, Lal BK, et al. Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis. J Vasc Surg, 2024, 79(3): 695-703.
7. Malas MB, Leal Lorenzo JI, Nejim B, et al. Analysis of the ROADSTER pivotal and extended-access cohorts shows excellent 1-year durability of transcarotid stenting with dynamic flow reversal. J Vasc Surg, 2019, 69(6): 1786-1796.
8. Kashyap VS, So KL, Schneider PA, et al. One-year outcomes after transcarotid artery revascularization (TCAR) in the ROADSTER 2 trial. J Vasc Surg, 2022, 76(2): 466-473. e1. doi: 10.1016/j.jvs.2022.03.872.
9. Wang J, Bai X, Wang T, et al. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis: a systematic review and meta-analysis. Stroke, 2022, 53(10): 3047-3054.
10. Saratzis A, Naylor R. 30 day outcomes after carotid interventions: an updated meta-analysis of randomised controlled trials in asymptomatic patients. Eur J Vasc Endovasc Surg, 2022, 63(1): 157-158.
11. Naazie IN, Cui CL, Osaghae I, et al. A systematic review and meta-analysis of transcarotid artery revascularization with dynamic flow reversal versus transfemoral carotid artery stenting and carotid endarterectomy. Ann Vasc Surg, 2020, 69: 426-436.
12. Malas MB, Dakour-Aridi H, Kashyap VS, et al. Transcarotid revascularization with dynamic flow reversal versus carotid endarterectomy in the vascular quality initiative surveillance project. Ann Surg, 2022, 276(2): 398-403.
13. Malas MB, Elsayed N, Naazie I, et al. Propensity score-matched analysis of 1-year outcomes of transcarotid revascularization with dynamic flow reversal, carotid endarterectomy, and transfemoral carotid artery stenting. J Vasc Surg, 2022, 75(1): 213-222.
14. Wu H, Wang Z, Li M, et al. Outcomes of transcarotid artery revascularization: a systematic review. Interv Neuroradiol, 2024, 30(3): 396-403.
15. Olesen ND, Frederiksen HJ, Storkholm JH, et al. Internal carotid artery blood flow is enhanced by elevating blood pressure during combined propofol-remifentanil and thoracic epidural anaesthesia: a randomised cross-over trial. Eur J Anaesthesiol, 2020, 37(6): 482-490.
16. Lee D, Batista PM, McMackin KK, et al. Intraoperative blood pressure lability carries a higher risk of headache after carotid endarterectomy. J Vasc Surg, 2022, 75(2): 592-598.
17. Kawamata T, Okada Y, Kawashima A, et al. Postcarotid endarterectomy cerebral hyperperfusion can be prevented by minimizing intraoperative cerebral ischemia and strict postoperative blood pressure control under continuous sedation. Neurosurgery, 2009, 64(3): 447-453.
18. Yang X, Liu Z, Hu C, et al. Incidence and risk factors for hypotension after carotid artery stenting: systematic review and meta-analysis. Int J Stroke, 2024, 19(1): 40-49.
19. G?k?al E, Niftaliyev E, Deniz ?, et al. Prolonged hypotension after carotid artery stenting: incidence, predictors and consequences. Acta Neurochir (Wien), 2017, 159(11): 2081-2087.
20. Nanto M, Goto Y, Yamamoto H, et al. Complications and predictors of hypotension requiring vasopressor after carotid artery stenting. Neurol Med Chir (Tokyo), 2017, 57(3): 115-121.
21. Dangas G, Laird JR, Satler LF, et al. Postprocedural hypotension after carotid artery stent placement: predictors and short- and long-term clinical outcomes. Radiology, 2000, 215(3): 677-683.

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