Impact of flow reversal duration on neurological outcomes of transcarotid artery revascularization (TCAR)
Isaac N Naazie, Nadin Elsayed, Claire Janssen, John Lane, Mahmoud Malas
University of California San Diego, La Jolla, CA
INTRODUCTION: Flow reversal is a key component of transcarotid artery revascularization (TCAR). However, the duration of flow reversal which optimizes TCAR outcomes is not known. We evaluated the association of flow reversal time with the intraoperative and postoperative neurological outcomes of TCAR
METHODS: We studied patients all undergoing TCAR from September 2016 to June 2021. The exposure of interest was the duration of flow reversal. Using multivariable fractional polynomial models, we identified a flow reversal time cutoff (10 minutes) which best predicts perioperative neurological events. Outcomes were compared with regards to this cutoff stratified by symptomatic status. Outcomes were intraoperative neurological change/intolerance, in-hospital stroke, and stroke/death. Multivariable logistic regression models were used to control for confounders for the entire cohort and then stratified by symptomatic status
RESULTS: A total of 17,106 patients were studied. A flow reversal time of 10 mins was identified as the critical cutoff predictive of neurological events. Flow reversal was applied for a duration of more than 10 mins in 47.7% of patients (n=8156). Patients in which flow reversal time was longer that 10 mins were less likely to have contralateral occlusion (7.0% vs 8.4%, P=0.001) but more likely to be obese (34.5% vs 32.6%, P=0.009), have COPD (26.7% vs 24.6%; P=0.002), be on preoperative aspirin (90.5% vs 89.5%; P=0.040) and statins (90.4% vs 89.2%; P=0.007), and to undergo TCAR under general anesthesia (84.0% vs 82.2%; P=0.002). Flow reversal beyond 10 mins was not significantly associated with outcomes among asymptomatic patients. Among symptomatic patients however, flow reversal time ≥ 10 mins was associated with 2-fold increased odds of intraoperative neurological intolerance (1.0% vs 0.5%; aOR, 2.18; 95%CI, 1.11-4.27; P=0.023), 2-fold increased odds of in-hospital stroke (2.8% vs 1.5%; aOR, 1.98; 95%CI, 1.35-2.92; P=0.001) and 92% increased odds in-hospital stroke/death (3.2% vs 1.7%; aOR, 1.92; 95%CI, 1.34-2.74; P<0.001) CONCLUSIONS: This study identified 10 minutes as the critical cutoff for flow reversal time which optimizes outcomes of TCAR. Beyond this cutoff, symptomatic patients demonstrated increased risk of neurological intolerance, in-hospital stroke, and stroke/death. We suggest that flow reversal time is limited to up to 10 minutes if technically possible in order to optimize TCAR outcomes.
| Overall | Asymptomatic | Symptomatic | ||||
| Outcome | aOR (95%CI) | P value | aOR (95%CI) | P value | aOR (95%CI) | P value |
| Intraoperative neurological changes | 1.85 (1.21-2.82) | 0.005 | 1.61 (0.92-2.80) | 0.093 | 2.18 (1.11-4.27) | 0.023 |
| In-hospital stroke | 1.66 (1.23-2.17) | <0.001 | 1.38 (0.95-2.01) | 0.940 | 1.98 (1.35-2.92) | 0.001 |
| In-hospital stroke/death | 1.36 (1.08-1.73) | 0.011 | 1.00 (0.72-1.40) | 0.982 | 1.92 (1.34-2.74) | <0.001 |
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