Balceniuk Mark D, Gonring Dakota, Wang Maxwell, Westfall Cynthia, Portanova Anthony, Stoner Michael C, Mix Doran S
Division of Vascular Surgery, Department of Surgery, University of Rochester, Rochester, NY.
Division of Neuroradiology, Department of Imaging Sciences, University of Rochester, Rochester, NY.
J Vasc Surg Cases Innov Tech. 2023 Jan 14;9(1):101102. doi: 10.1016/j.jvscit.2023.101102. eCollection 2023 Mar.
Transcarotid artery revascularization (TCAR) has been used with increasing prevalence for treatment of carotid artery stenosis. TCAR holds potential benefits over traditional carotid endarterectomy (CEA) or transfemoral carotid artery stenting by its nature of being less invasive than CEA but more neuroprotective than transfemoral carotid artery stenting. The purpose of this pilot study is to evaluate the effectiveness of the neuroprotection system of TCAR with flow reversal by quantifying the incidence and degree of new intracerebral lesions using diffusion-weighted magnetic resonance imaging (DW-MRI). This study is the first to evaluate these findings in a real-world, high-risk cohort, who would have been excluded from the ROADSTER and ENROUTE transcarotid neuroprotection system DW-MRI studies.
Patients undergoing unilateral TCAR for symptomatic or asymptomatic severe internal carotid artery disease were eligible and prospectively enrolled in the study. All patients had high risk features, including comorbidities or medications, which excluded them from industry-sponsored DW-MRI trials. Patients underwent a preoperative DW-MRI to obtain a baseline intracerebral evaluation within 1 week of the scheduled surgery. The follow-up DW-MRI occurred within 48 hours postoperatively. The primary outcome was new, acute postoperative lesion(s) identified on DW-MRI. Secondary outcomes include any major stroke, myocardial infarction, or death during hospitalization.
Five consecutive patients underwent TCAR with preoperative and postoperative imaging. All five patients were on dual antiplatelet therapy before their procedure and verified to be therapeutic on these agents. All patients underwent a right-sided TCAR and three were symptomatic as the indication for their procedure. All five patients demonstrated chronic lesions on the preoperative DW-MRI. Technical success was achieved in all five patients, with one operative complication involving a dissection of the common carotid at the access site, which was stented using the TCAR system. Postoperative DW-MRI did not identify any new intracerebral lesions in any patient following the procedure. No patient had a stroke, myocardial infarction, or death during hospitalization.
In this real-world, high-risk cohort, TCAR was completed with no evidence of new, postoperative DW-MRI lesions. These data further demonstrate that TCAR with flow reversal is an effective neuroprotective strategy for carotid revascularization. Further study is warranted to evaluate DW-MRI differences between TCAR and CEA.
经颈动脉血管重建术（TCAR）在治疗颈动脉狭窄中的应用日益普遍。与传统的颈动脉内膜切除术（CEA）或经股动脉颈动脉支架置入术相比，TCAR具有潜在优势，其侵入性小于CEA，但神经保护作用优于经股动脉颈动脉支架置入术。本前瞻性研究旨在通过弥散加权磁共振成像（DW-MRI）量化新的脑内病变的发生率和程度，评估血流逆转的TCAR神经保护系统的有效性。本研究首次在真实世界的高危队列中评估这些结果，这些患者被排除在ROADSTER和ENROUTE经颈动脉神经保护系统DW-MRI研究之外。
因有症状或无症状的严重颈内动脉疾病接受单侧TCAR的患者符合条件并前瞻性纳入本研究。所有患者均具有高风险特征，包括合并症或正在服用的药物，这使他们被排除在行业赞助的DW-MRI试验之外。患者在预定手术的1周内接受术前DW-MRI检查，以获得脑内基线评估。术后DW-MRI检查在术后48小时内进行。主要结局是DW-MRI上发现的新的急性术后病变。次要结局包括住院期间发生的任何严重卒中、心肌梗死或死亡。
连续5例患者接受了TCAR手术，并进行了术前和术后影像学检查。所有5例患者在手术前均接受双联抗血小板治疗，并证实这些药物治疗有效。所有患者均接受了右侧TCAR手术，其中3例有症状，作为手术指征。所有5例患者术前DW-MRI均显示有陈旧性病变。所有5例患者手术均获成功，1例手术并发症为穿刺部位颈总动脉夹层，使用TCAR系统置入支架。术后DW-MRI检查未发现任何患者有新的脑内病变。住院期间无患者发生卒中、心肌梗死或死亡。
在这个真实世界的高危队列中，完成TCAR手术后未发现新的术后DW-MRI病变。这些数据进一步表明，血流逆转的TCAR是一种有效的颈动脉血管重建神经保护策略。有必要进一步研究以评估TCAR和CEA之间DW-MRI的差异。
