Less-invasive stenting procedure linked to better outcomes in patients at risk for stroke

Study demonstrates newer technique is linked to lower risk of stroke and death in patients with carotid artery stenosis.

Boston, Mass. – Located on either side of the neck, the carotid arteries supply the face and brain with blood. Narrowing of these arteries, a condition called carotid artery stenosis, occurs when the blood vessels become clogged with cholesterol and fatty deposits. Stroke can occur if debris from the fatty deposits, also known as carotid plaque, becomes unstable and travels to the brain.

A recently-developed carotid stenting procedure intended to lower the risk of stroke in at-risk patients is safer than traditional carotid stenting techniques, according to a new study led by surgeons from Beth Israel Deaconess Medical Center (BIDMC). Known as transcarotid artery revascularization (TCAR), a novel stenting technique developed in 2015 was found to be associated with a significantly lower risk of stroke or death compared to the stenting procedure in widespread use today. Among the first to characterize outcomes of TCAR compared to traditional techniques, the study was published in the Journal of the American Medical Association (JAMA).

“Our findings highlight the ability of TCAR to provide patients with a safer method for carotid artery stenting,” said Marc L. Schermerhorn, MD, Chief of the Division of Vascular and Endovascular Surgery at BIDMC. “TCAR is currently reserved for high surgical risk patients, but with these data, it is possible that TCAR will be expanded in the future to serve as an option for normal risk patients and become a predominant modality for the treatment of carotid stenosis.”

To reduce the risk of stroke in patients with carotid artery stenosis, surgeons may opt to restore normal blood flow to the brain either by surgically removing the carotid plaque or by carotid stenting, a less invasive technique to widen narrowed arteries. An older stenting technique, known as transfemoral carotid artery stenting, has been found in several randomized clinical trials to carry a higher risk of perioperative stroke compared to open surgical revascularization.

Intended to decrease the risk of perioperative stroke during carotid stenting, TCAR utilizes a more direct approach as well as a new neuroprotection system. However, significant outcomes differences between patients undergoing TCAR compared to transfemoral carotid artery stenting have not been described prior to this publication.

Schermerhorn, who is also the George H. A. Clowes Jr. Professor of Surgery at Harvard Medical School, is the lead investigator for the Vascular Quality Initiative (VQI) TransCarotid Revascularization Surveillance Project, a registry which captures more than 95 percent of all TCAR procedures performed nationally. Using data from this registry, Schermerhorn and colleagues – including co-first author Patric Liang, MD, a clinical fellow in surgery at BIDMC – looked at outcomes for more than 3,000 matched pairs of patients who underwent transcarotid artery revascularization or transfemoral carotid artery stenting between September 2016 and April 2019. The team found that the in-hospital risk of stroke or death was 1.6 percent with the TCAR approach, versus 3.1 percent with the transfemoral carotid artery stenting technique, a statistically significant difference. Additionally, the risk of stroke or death was also lower with the TCAR approach at one-year after the procedure.

“We expect that these results showing the superiority of TCAR over traditional transfemoral stenting will accelerate the increasing utilization of TCAR over transfemoral stenting,” Schermerhorn said. “The next step will be to compare TCAR to transfemoral stenting as well as other treatment modalities in patients who are not high risk.”

“The development of this transcarotid stenting technique is a breakthrough for the technological advancement of carotid stenting, offering a safe, minimally invasive option for more patients with carotid disease,” said Liang. “This study shows the ability of the VQI registry to examine real-world outcomes in patients treated for vascular disease, to help determine what treatment options are best for patients.”

In addition to Schermerhorn and Liang, co-authors included Jens Eldrup-Jorgensen, MD, and Brian W. Nolan, MD of  Maine Medical Center; Jack L. Cronenwett, MD, of Dartmouth-Hitchcock Medical Center; Vikram S. Kashyap, MD, of University Hospitals Cleveland Medical Center; Grace J. Wang, MD, MSCE, of the Hospital of the University of Pennsylvania; Raghu L. Montaganahalli, MD, of Indiana University School of Medicine; and Mahmoud B. Malas, MD, MHS, of University of California San Diego Health System.

This work was supported by the Harvard-Longwood Research Training in Vascular Surgery National Institutes of Health (NIH) T32 grant (5T32HL007734-22); Harvard Catalyst – The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH award (UL1 TR001102), and financial contributions from Harvard University and its affiliated academic health care centers. 

Dr. Schermerhorn has provided consultancy services for Silk Road Medical, Abbott, Cook, Endologix and Medtronic outside the submitted work. Please see the published article for further disclosures.