Systematic review of embolic activity and cerebral hemodynamics in transcarotid artery revascularization using transcranial Doppler ultrasound

Background Transcarotid artery revascularization (TCAR) is a safer alternative to transfemoral carotid artery stenting (tfCAS), utilizing flow reversal to reduce embolic risk from wire manipulation. Intraoperative transcranial Doppler (TCD) enables real-time monitoring of cerebral hemodynamics and embolic events during TCAR. This review evaluates TCD's findings in enhancing the safety and outcomes of TCAR. Methods We conducted a systematic review following PRISMA guidelines. A comprehensive search of PubMed, Embase, and Scopus was conducted to identify relevant studies from the earliest available records through January 2025. Eligible studies were original English-language research articles—including case series, case-control studies, retrospective or prospective cohort studies, and randomized controlled trials—reporting intraoperative TCD findings during TCAR. Studies comparing TCD findings in TCAR with other revascularization methods, such as carotid endarterectomy (CEA) and tfCAS were also included. Outcomes extracted focused on embolic burden (measured by high-intensity transient signals, HITS) and mean flow velocity (MFV) of the middle cerebral artery (MCA), both overall and at specific procedural stages. Meta-analysis was not feasible due to heterogeneity in study designs, outcome measures, and TCD protocols among the included studies. Results Thirteen studies were included. Earlier TCD assessments during TCAR reported no embolic events, while more recent studies found mean embolic counts ranging from 0 to 29, indicating a generally low embolic burden. Larger embolic showers, with counts between 117 and 184 HITS, were also reported. The highest embolic activity occurred during stent deployment and after flow reversal cessation, with median HITS counts across studies ranging from 8–16 and 34–56, respectively. Across the included studies, TCAR was associated with a lower embolic burden than tfCAS, with reported median HITS values ranging from 0 to 184 for TCAR, compared to 197 to 584 for tfCAS, particularly during lesion crossing, pre-dilation, and post-dilation phases. Comparisons with CEA were mixed: one study showed lower HITS in CEA, while another found no difference. Consistently, studies reported a significant MFV drop during flow reversal, particularly in patients with an incomplete circle of Willis. MFV returned to or exceeded baseline after flow reversal, indicating effective cerebral perfusion restoration. Although the literature does not consistently link intraoperative TCD findings to postoperative stroke outcomes, one study found that patients with fewer than 20 HITS had significantly greater improvement in postoperative Glasgow Coma Scale scores (p = 0.028), suggesting a potential cognitive benefit from reduced embolic burden. Conclusion These findings demonstrate the capability of intraoperative TCD to detect embolic and hemodynamic changes during TCAR, particularly in identifying high-risk procedural phases. While TCAR shows a lower embolic burden than tfCAS, further research is warranted to refine TCD techniques and determine their clinical utility and impact on patient outcomes.