Impact of Flow Reversal Duration on Stroke Risk in Patients Undergoing TCAR

Transcarotid artery revascularization (TCAR) has been shown to be an effective treatment for atherosclerotic carotid artery disease, utilizing the technique of flow reversal for distal embolic protection. However, a paucity of literature exists examining the exact impact of flow reversal time and how the duration of flow reversal in patients undergoing TCAR may impact neurological outcomes and stroke risk. The primary objective of this study is to investigate the direct association between the flow reversal time and stroke risk in patients undergoing TCAR. The Vascular Quality Initiative (VQI) database was utilized to identify a total of 24,228 patients undergoing TCAR from 2016 to 2023. Inclusion criteria included all patients undergoing first-time elective TCAR. Logistic regression analysis was utilized to assess the association between flow reversal times and neurological complications in patients. Level of significance was set at 5% and all analyses were conducted using SAS software. A total of 24,228 patients undergoing first-time, elective TCAR were identified for the study. Mean age of patients was 73.5 (± 8.8) years old. Males comprised 62.7% (n = 15,196), and women comprised 37.3% (n = 9032) of the study population. Of the study group, 63.2% (n = 15,302) of patients had asymptomatic carotid artery stenosis and 36.8% (n = 8926) had symptomatic carotid artery stenosis. In patients with asymptomatic carotid stenosis, increased flow reversal time was significantly associated with an increased stroke risk (OR, 1.021; 95% CI, 1.008-1.034; P = .0015). For every 1-minute increase in flow reversal time, the odds of intraoperative and postoperative stroke were increased by 2.1%. In patients with symptomatic carotid artery stenosis, increased flow reversal time was also significantly associated with an increased stroke risk (OR, 1.016; 95% CI, 1.003-1.029). For every 1-minute increase in flow reversal time, the odds of intraoperative and postoperative stroke were increased by 1.6%. Our study demonstrates that the duration of flow reversal time in patients undergoing TCAR is significantly associated with stroke risk in patients undergoing TCAR for both symptomatic and asymptomatic carotid artery disease, with each additional minute of flow reversal conferring an additional stroke risk. Thus, minimizing the duration of flow reversal time may be an important technical consideration for vascular surgeons in performing TCAR.