When it comes to the ongoing debate of carotid endarterectomy (CEA) versus transcarotid artery revascularisation (TCAR) in the treatment of carotid artery stenosis, operators should be comfortable and maintain experience with both of these procedures—and “collaborate as needed.” That is the ultimate finding of a registry analysis set to be presented later this week at the 2024 Vascular Annual Meeting (VAM; 19–22 June, Chicago, USA) during Plenary Session 1: William J von Liebig Forum.
The analysis in question will be delivered by Andrea Alonso (Boston University, Boston, USA) on behalf of lead author Jeffrey J Siracuse (Boston University, Boston, USA) and colleagues.
“Our study observed an inverse relationship between the proportion of a procedure—either TCAR or CEA—conducted by a surgeon, and the rate of postoperative stroke, with surgeons performing the lowest proportion having the highest stroke rates,” Alonso told Vascular Specialist. “Our data also suggest that, among surgeons with a more balanced practice, there continues to be a low rate of stroke. To minimise postoperative stroke risk, we conclude that surgeons who offer both types of carotid revascularisation procedures maintain a balance. We also suggest collaboration in challenging cases, leveraging the diverse expertise within a practice, to reduce stroke risk.
“We believe that this can be done effectively in the preoperative setting while evaluating challenging cases and with advanced coordination with colleagues to assist in key parts of the operation. This step takes insight from the lead surgeon to recognise the surgical techniques that they may require more assistance with at that stage in their practice, as well as camaraderie within the practice group.”
According to the authors, TCAR adoption among surgeons has been variable—many still perform more traditional CEAs, while others have shifted mostly to TCAR in their practice. Researchers therefore set out to evaluate the association between surgeons’ relative volumes of CEA to TCAR, and perioperative outcomes, via analyses of the Vascular Quality Initiative (VQI) CEA and carotid artery stenting (CAS) registries from 2021–2023.
Across both registries, participating surgeons were categorised in the following CEA/TCAR volume percentage ratios: 0–25/76–100 (majority TCAR); 26–50/51–75 (more TCAR); 51–75/26–50 (more CEA); and 76–100/1–25 (majority CEA). Primary outcome measures for the analysis consisted of rates of perioperative ipsilateral stroke, death, cranial nerve injury (CNI) and return to the operating room (RTOR) for bleeding.
The researchers found that there were 50,189 patients who underwent primary carotid revascularisations (CEA, 64.3%; TCAR, 35.7%), also noting that—on average—CEA patients were younger (71.1 vs. 73.5 years, p<0.001), with less coronary artery disease and diabetes, fewer symptomatic cases, and lower antiplatelet and statin use (all p<0.001). Meanwhile, they observed that TCAR patients had lower rates of end-stage renal disease, smoking and obesity (all p<0.001).
Postoperative stroke after CEA was found to be significantly impacted by relative surgeon volume ratio (p=0.04), with “majority TCAR” surgeons having higher rates of postoperative ipsilateral stroke (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.15–3.9; p=0.02). Alonso, Siracuse and colleagues have also reported that there was a trend indicating a higher stroke rate after TCAR in “majority CEA” surgeons—however, this did not reach statistical significance. In addition, they saw no association between relative volumes and perioperative death, CNI or bleeding-related RTOR for either procedure.
It is based upon these findings that the researchers conclude that relative surgeon ratios of CEA versus TCAR do appear to influence perioperative stroke rates when it comes to CEA, emphasising the need for surgeons to be familiar with both procedures and utilise collaboration.
“There are multiple positive impacts that can arise from these kinds of collaboration,” Alonso added. “Principally, one is a reduction in patient stroke rate, particularly for patients with challenging disease. Other positive impacts include continued teamwork and mentorship within a practice, as well as the exchange of perspectives, practice techniques and ideas among surgeons from different training backgrounds.”
