Utilization of the stop-short technique in transcarotid artery revascularization is associated with intraoperative common carotid artery dissection.

Abstract

Transcarotid artery revascularization (TCAR) has gained widespread adoption for carotid revascularization since the US Food and Drug Administration approved it for use in 2015. Intraoperative common carotid artery (CCA) dissection during the procedure remains a feared complication. However, data describing CCA dissection incidence and ways to mitigate it remain limited. We analyzed a contemporary, manufacturer-maintained registry to determine the incidence, risk factors, management strategies, and clinical outcomes of CCA dissection during TCAR. We retrospectively analyzed the Silk Road Medical registry, which included all TCAR procedures performed between January 2023 and January 2024. We identified cases of CCA dissection, recorded the procedural step during which they occurred, and reviewed management strategies and perioperative acute stroke events. We used multivariable logistic regression to identify patient and procedural characteristics associated with CCA dissection and compared procedural metrics between patients with vs without CCA dissection. Of 25,346 patients undergoing TCAR (median age, 74 years; 61.9 % male), 300 (1.18%) experienced a CCA dissection. CCA dissections occurred most commonly during arterial sheath insertion (61.7%), followed by micropuncture access (21.7%) and guidewire manipulation (12.0%). Surgeons managed dissections with additional stent deployment (41.0%), conversion to carotid endarterectomy (22.0%), or other open surgical repairs (6.7%). Acute stroke events occurred in 2.3% of patients with CCA dissection (7/300). After risk adjustment, factors associated with CCA dissection included age ≥85 years (vs <65 years; adjusted odd ratio [aOR], 1.82; 95% confidence interval [CI], 1.17-3.02), female sex (aOR, 1.65; 95% CI, 1.31-2.07), and use of the stop-short technique (ie, maintaining the stiff guidewire within the CCA during sheath insertion instead of advancing to the external carotid artery [aOR, 2.25; 95% CI, 1.70-3.02]). Patients with CCA dissection had longer procedure times, greater fluoroscopy exposure, higher contrast use, and more frequent use of two or more stents compared to patients without CCA dissection (all P < .001). TCAR demonstrates a favorable safety profile, with a low incidence of intraoperative CCA dissection. Use of the stop-short technique was associated with a two-fold increase in the risk of CCA dissection. Surgeons should engage the external carotid artery during sheath insertion whenever possible to minimize the risk of CCA dissection.