Preliminary experience with transcarotid artery revascularization for the treatment of carotid artery stenosis in Chinese population

Lu Xia; Sun Bin; Tao Yunlu; Ma Yan; Yang Bin; Gao Peng; Wang Yabing; Chen Jian; Liu Dianwei; Zhao Yanxin; Chen Fei; Tsz Yeung Lau; Xing Yingqi; Jiao Liqun

doi:10.3969/j.issn.1672-5921.2025.12.005

Abstract：Objective To summarize the preliminary experience of applying transcarotid artery revascularization(TCAR)for the treatment of patients with carotid artery stenosis.Methods This study retrospectively and consecutively enrolled patients with carotid artery stenosis who underwent TCAR treatment between March 2025 and May 2025 at the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University,and the Stroke Center,Xuanwu Hospital,Capital Medical University,Jinan Branch.Demographic characteristics and preoperative evaluation data were collected,including sex,age,side of stenosis,stenosis rate,symptomatic status,aortic arch type(Myla classification type Ⅰ,Ⅱ and Ⅲ),level of carotid bifurcation,and presence of communicating arteries.All operators were chief physicians with over 10 years of experience in independently performing carotid endarterectomy(CEA)and transfemoral carotid artery stenting(TF-CAS).The first TCAR case for each operator was completed under the guidance of a technically proficient surgeon.Indicators on surgical performance included anesthesia time,intraoperative common carotid artery(CCA)clamping duration,residual stenosis rate,new infarct on diffusion-weighted imaging(DWI)within 48 hours postoperatively and their locations(cortex,subcortical white matter,centrum semiovale,periventricular white matter,basal ganglia).For patients with intraoperative transcranial Doppler(TCD)monitoring,the number of microemboli at different time points(before CCA clamping,after CCA clamping,after stent implantation,after CCA clamping removed,at the end of surgery)and the mean flow velocity of the ipsilateral middle cerebral artery(MCA;baseline,after clamping,ratio of baseline to post-clamping)were recorded.Technical success was defined as immediate post-procedural angiography showing complete coverage of the stenotic lesion by the stent with residual stenosis＜50%.Postoperative complications included new ischemic stroke within 30 days,any intracranial hemorrhage,and other conditions leading to a postoperative hospital stay exceeding 10 days.Results A total of 8 patients with carotid artery stenosis who underwent TCAR were enrolled,comprising 7 males and 1 female,aged 62-71 years with a mean age of(68±3)years.There were 2 cases of right carotid artery stenosis and 6 cases of left carotid artery stenosis,all being severe stenoses with a mean stenosis rate of(83.3±7.4)%.Symptomatic and asymptomatic stenoses each accounted for 4 cases.Aortic arch types Ⅰ,Ⅱ,and Ⅲ were observed in 6 cases,1 case,and 1 case,respectively.The carotid bifurcation was level with the C3 and C4 vertebral bodies in 3 cases each,and between C4 and C3 in 2 cases.Two patients lacked both anterior and posterior communicating arteries.TCAR was technically successful in all 8patients without clinical complications.The mean anesthesia time was(182.50±47.90)min,the mean CCA clamping time was(21.63±10.58)min,and the mean residual stenosis rate was(13.4±12.2)%.Three patients had new infarct foci on DWI within 48 hours postoperatively,with 2 located in the cortex and 1 in the periventricular white matter.TCAR was performed by 5 operators.For the first TCAR case of each operator,the mean anesthesia time was(185.40±58.53)min and the mean CCA clamping time was(24.80±11.97)min.Operator who performed the highest number of cases(3cases),had a mean patient anesthesia time of(156.33±34.37)min and a mean CCA clamping time of(14.00±2.94)min.Seven patients underwent intraoperative TCD monitoring.After CCA clamping,the mean MCA flow velocity on the operated side decreased in all 7 patients,averaging(65.53±12.23)%of the baseline value.Microembolic signals were detected intraoperatively in all 7patients,with a mean cumulative count of(30.00±24.87)microemboli by the end of the procedure.There were still microemboli detected during CCA clamping in 4 patients.Conclusion For surgical teams proficient in TF-CAS and CEA techniques,under the guidance of experienced surgeons and with the intraoperative TCD monitoring,performing TCAR for Chinese patients with carotid artery stenosis meeting specific vascular anatomical conditions appears to be safe and effective.The findings of this study require further validation through large-scale multicenter clinical trials.