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Utilization of the Stop Short Technique in Transcarotid Artery Revascularization Doubles the Risk of Intraoperative Common Carotid Artery Dissection
Y.H. Andrew Wu
1, Roberto G. Aru
2, Jamie Schwartz
1, Solomon Mulugeta
3, Chen Dun
1, Christopher J. Abularrage
1, Michael C. Stoner
4, Jesse A. Columbo
5, Sumaira Macdonald
3, Caitlin W. Hicks
1 1Johns Hopkins Hospital, Baltimore, MD;
2Thomas Jefferson University, Philadelphia, PA;
3Silk Road Medical, Inc., Sunnyvale, CA;
4University of Rochester Medical Center, Rochester, NY;
5Dartmouth Hitchcock Medical Center, Lebanon, NH
INTRODUCTION: Since FDA approval in 2015, transcarotid artery revascularization (TCAR) has been rapidly adopted as one of three primary approaches for carotid revascularization. However, there have been anecdotal concerns about the risk of intraprocedural common carotid artery (CCA) dissection that remain poorly defined. We aimed to evaluate the incidence of CCA dissection and factors associated with its occurrence during TCAR.
METHODS: We performed a retrospective analysis of internal manufacturer registry data (Silk Road Medical, Inc.) from January 2023 to January 2024 that captured all patients who underwent TCAR. We reviewed the FDA-compliant complaint-tracking system to identify CCA dissection complications, and used the International Medical Device Regulators Forum codes to classify device adverse events associated with TCAR. We reported the incidence of CCA dissection and used multivariable logistic regression to evaluate risk factors associated with CCA dissection during TCAR.
RESULTS: We identified 25,346 patients who underwent TCAR during the study period (median age 74 years, 37.1% female, 62.8% using the stop short technique [i.e., keeping the wire in the CCA during sheath insertion, compared to selecting the external carotid artery]). Overall, 1.18% experienced a CCA dissection related to the procedure. Risk factors for CCA dissection included advanced age ≥ 85 years (vs. <65 years, aOR 1.82, 95% CI 1.16-2.85), female sex (aOR 1.61, 95% CI 1.27-2.04), and use of the stop short technique (aOR 2.28, 95% CI 1.71-3.04). High-risk anatomical factors, medical comorbidities, and indirect arterial sheath access (via tunneling or a conduit) were not associated with CCA dissection (Figure 1). Patients with CCA dissection had longer overall procedural time, flow reversal time, and fluoroscopy exposure time, and required greater volume of contrast use and a higher frequency of getting two or more stents compared to patients without CCA dissection (all, P<0.001; Figure 2). Among patients who experienced a CCA dissection, 34.3% (103/300) required surgical repair and 2.3% (7/300) suffered from an acute stroke.
CONCLUSIONS: The stop short technique during TCAR sheath insertion, which was used in the majority of cases, is associated with a more than two-fold increased odds of CCA dissection. Surgeons should consider selection of the external carotid artery prior to sheath insertion whenever possible to reduce the dissection risk. Despite this, the incidence of CCA dissection during TCAR is rare and stroke sequelae are uncommon, reinforcing TCAR as a relatively safe method for managing carotid artery stenosis.
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