Procedural Complexity of TransCarotid Artery Revascularization (TCAR) is not Increased in Irradiated and Reoperative Necks

Abstract Objective TransCarotid Revascularization (TCAR) with dynamic flow reversal using the ENROUTE Neuroprotection System (ENPS) is an FDA-approved alternative carotid revascularization modality. The purpose of this investigation was to determine whether TCAR in a hostile (fibrotic) surgical field increases procedural complexity and postoperative complications. Methods Perioperative variables for all institutional TCARs performed between December 2015 and April 2019 were prospectively captured. Procedures performed as part of the ongoing ROADSTER-2 registry were excluded. Univariate analysis, consisting of Student’s T- and Fisher’s Exact Testing, comparing virgin and hostile neck TCAR was performed at an alpha of 0.05. Results During the study period, 149 total procedures (n=30 hostile ipsilateral necks) qualified for inclusion. Both hostile and virgin neck groups were comparable with respect to preoperative comorbidities and medication profiles. The ipsilateral hostile neck cohort consisted of ten patients who underwent previous ipsilateral neck radiation and 23 who were status post neck dissection (three had both). Intraoperatively, there were no differences with respect to estimated blood loss (47.2 vs 44.8 mLs, p=0.81), operative time (69.5 vs 74.5 mins, p=0.38), reverse flow time (12.4 vs 10.4 mins, p=0.34), radiation exposure (217.7 vs 226.2 mGy, p=0.88), fluoroscopy time (5.4 vs 5.0 mins, p=0.65), contrast usage (23.5 vs 25.0 mLs, p=0.55), and ability to achieve technical success (96.7% vs 100%, p=0.58) between virgin and hostile necks, respectively. Perioperative (30-day) ipsilateral stroke and death rate was 2.5% vs 0% (p=1.0) and 2.5% vs 0% (p=1.0), respectively, between virgin and hostile necks. We observed one postoperative cranial nerve injury in any of our TCAR patients (hostile neck, p=0.20). Lastly, a total of three hematomas (requiring washout) occurred in our (two in virgin necks, one in a hostile neck) surgical cohort (p=0.49). Conclusions Based on this limited, small series, TCAR in hostile surgical fields is not associated with an increase in case complexity and maintains a similar perioperative risk to virgin field procedures.