Direct Transcervical Access vs the Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta-Analysis

Abstract

Purpose: To examine the safety profile of transcervical access (TCA) in comparison with the transfemoral approach (TFA) in carotid artery stenting. Materials and Methods: A systematic review and meta-analysis was performed according to current guidelines. Eleven eligible studies including 11,592 patients (10,736 in the TFA group and 856 in the TCA group) were identified through a search of the PubMed, Scopus, and Cochrane databases up to October 2018. A random effects model meta-analysis was conducted, and the I² statistic was used to assess heterogeneity. Publication bias was assessed using funnel plots and quantified using the Egger method. Results: The TFA group had a statistically significantly higher risk of periprocedural (30-day) stroke compared with the TCA group (OR 1.98, 95% CI 1.08 to 3.63, p=0.027; I²=0%). Also, patients in the TFA group had a significantly higher risk of developing new ischemic lesions (OR 2.97, 95% CI 1.48 to 5.96, p=0.002; I²=0%) on diffusion-weighted magnetic resonance imaging (DW-MRI). No differences in terms of transient ischemic attack (OR 1.50, 95% CI 0.73 to 3.10, p=0.268; I²=5.9%), myocardial infarction (OR 0.64, 95% CI 0.30 to 1.35; p=0.242; I²=0%), local hematoma (OR 0.53, 95% CI 0.12 to 2.25, p=0.389; I²=0%), or mortality (OR 1.35, 95% CI 0.62 to 2.92, p=0.449; I²=0%) were identified between the groups. Conclusion: TCA is associated with a significantly lower risk for periprocedural stroke and DW-MRI ischemic lesions compared with TFA. Other periprocedural outcomes were similar between the groups.

Keywords

carotid artery stenting common carotid artery common femoral artery diffusion-weighted magnetic resonance imaging mortality myocardial infarction stroke transient ischemic attack vascular access

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References

Brott

Hobson

2nd Howard

et al . Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363:11–23.

Yadav

Wholey

Kuntz

et al . Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351:1493–1501.

Sardar

Chatterjee

Aronow

et al . Carotid artery stenting versus endarterectomy for stroke prevention: a meta-analysis of clinical trials. J Am Coll Cardiol. 2017;69:2266–2275.

Sheffet

Roubin

Howard

et al . Design of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST). Int J Stroke. 2010;5(1):40–46.

Tadros

Vouyouka

Chung

et al . The effect of statin use on embolic potential during carotid angioplasty and stenting. Ann Vasc Surg. 2013;27:96–103.

Tedesco

Lee

Dalman

et al . Postprocedural microembolic events following carotid surgery and carotid angioplasty and stenting. J Vasc Surg. 2007;46:244–250.

Wissgott

Schmidt

Brandt-Wunderlich

et al . Clinical results and mechanical properties of the carotid CGUARD double-layered embolic prevention stent. J Endovasc Ther. 2017;24:130–137.

Varbella

Gagnor

Rolfo

et al . Feasibility of carotid artery stenting with double cerebral embolic protection in high-risk patients. Catheter Cardiovasc Interv. 2016;87:432–437.

Texakalidis

Letsos

Kokkinidis

et al . Proximal embolic protection versus distal filter protection versus combined protection in carotid artery stenting: a systematic review and meta-analysis. Cardiovasc Revasc Med. 2018;19 (5 pt A):545–552.

10.

Schmidt

Diederich

Scheinert

et al . Effect of two different neuroprotection systems on microembolization during carotid artery stenting. J Am Coll Cardiol. 2004;44:1966–1969.

11.

Cano

Kambara

Cano

et al . Randomized comparison of distal and proximal cerebral protection during carotid artery stenting. JACC Cardiovasc Interv. 2013;6:1203–1209.

12.

Plessers

Van Herzeele

Hemelsoet

et al . Transcervical carotid stenting with dynamic flow reversal demonstrates embolization rates comparable to carotid endarterectomy. J Endovasc Ther. 2016;23:249–254.

13.

Palombo

Stella

Faraglia

et al . Cervical access for filter-protected carotid artery stenting: a useful tool to reduce cerebral embolisation. Eur J Vasc Endovasc Surg. 2010;39:252–257.

14.

Leal

Orgaz

Flores

et al . A diffusion-weighted magnetic resonance imaging-based study of transcervical carotid stenting with flow reversal versus transfemoral filter protection. J Vasc Surg. 2012;56:1585–1590.

15.

Pinter

Ribo

Loh

et al . Safety and feasibility of a novel transcervical access neuroprotection system for carotid artery stenting in the PROOF study. J Vasc Surg. 2011;54:1317–1323.

16.

Shamseer

Moher

Clarke

et al . Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;349:g7647.

17.

Plessers

Van Herzeele

Hemelsoet

et al . Perioperative embolization load and s-100β do not predict cognitive outcome after carotid revascularization. Ann Vasc Surg. 2016;36:175–181.

18.

Leal

Orgaz

Flores

et al . A diffusion-weighted magnetic resonance imaging–based study of transcervical carotid stenting with flow reversal versus transfemoral filter protection. J Vasc Surg. 2012;56:1585–1590.

19.

Wyers

Powell

Fillinger

et al . The value of 3D-CT angiographic assessment prior to carotid stenting. J Vasc Surg. 2009;49:614–622.

20.

Taha

Sakaida

Asakura

et al . Access site complications with carotid angioplasty and stenting. Surg Neurol. 2007;68:431–437.

21.

Lin

Kolvenbach

Pinter

Protected carotid artery stenting and angioplasty via transfemoral versus transcervical approaches. Vasc Endovascular Surg. 2005;39:499–503.

22.

Powell

Schermerhorn

Nolan

et al . Early results of carotid stent placement for treatment of extracranial carotid bifurcation occlusive disease. J Vasc Surg. 2004;39:1193–1199.

23.

Mathieu

Piret

Bergeron

et al . Choice of access for percutaneous carotid angioplasty and stenting: a comparative study on cervical and femoral access. J Cardiovasc Surg (Torino). 2009;50:677–681.

24.

Palombo

Faraglia

Stella

et al . Cerebral embolization during carotid stenting: cervical approach vs. transfemoral approach. Cerebrovasc Dis Conf 16th Meet Eur Soc Neurosonology Cereb Hemodynamics Munich Ger Conf Start. 2011;31(no pagination):0-1. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=emed10&AN=70431714%5Cnhttp://nt2yt7px7u.search.serialssolutions.com/?sid=OVID:Embase&genre=article&id=pmid:&id=doi:&issn=1015-9770&volume=31&issue=&spage=no+pagination&pages=no+paginatio.

25.

Malas

Dakour-Aridi

Wang

et al . Transcarotid artery revascularization versus transfemoral carotid artery stenting in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. 2019;69:92–103.e2.

26.

Higgins

JPT

Altman

Gøtzsche

et al . The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.

27.

Sweeting

Sutton

Lambert

PC.

What to add to nothing? Use and avoidance of continuity corrections in meta-analysis of sparse data. Stat Med. 2004;23:1351–1375.

28.

Higgins

JPT

Thompson

Deeks

et al . Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560.

29.

Sterne

JAC

Sutton

Ioannidis

JPA

et al . Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ. 2011;343:d4002.

30.

Criado

Doblas

Fontcuberta

et al . Transcervical carotid artery angioplasty and stenting with carotid flow reversal: surgical technique. Ann Vasc Surg. 2004;18:257–261.

31.

Flores

Doblas

Criado

Transcervical carotid artery stenting with flow reversal eliminates emboli during stenting: why does it work and what are the advantages with this approach. J Cardiovasc Surg (Torino). 2009;50:745–749.

32.

Christopoulos

Philippov

Kallintzi

Safe carotid artery angioplasty and stenting in patients unsuitable for transfemoral approach. Int Angiol. 2010;29:37–40.

33.

Lam

Lin

DeRubertis

et al . The impact of increasing age on anatomic factors affecting carotid angioplasty and stenting. J Vasc Surg. 2007;45:875–880.

34.

Lal

Brott

. The Carotid Revascularization Endarterectomy vs. Stenting Trial completes randomization: lessons learned and anticipated results. J Vasc Surg. 2009;50:1224–1231.

35.

Alvarez

Ribo

Maeso

et al . Transcervical carotid stenting with flow reversal is safe in octogenarians: A preliminary safety study. J Vasc Surg. 2008;47:96–100.

36.

Sfyroeras

Moulakakis

Markatis

et al . Results of carotid artery stenting with transcervical access. J Vasc Surg. 2013;58:1402–1407.

37.

Stabile

Sannino

Schiattarella

et al . Cerebral embolic lesions detected with diffusion-weighted magnetic resonance imaging following carotid artery stenting: a meta-analysis of 8 studies comparing filter cerebral protection and proximal balloon occlusion. JACC Cardiovasc Interv. 2014;7:1177–1183.

38.

Al-Mubarak

Roubin

Vitek

et al . Effect of the distal-balloon protection system on microembolization during carotid stenting. Circulation. 2001;104:1999–2002.

39.

Kakisis

JDD

Antonopoulos

CNN

Mantas

et al . Cranial nerve injury after carotid endarterectomy: incidence, risk factors, and time trends. Eur J Vasc Endovasc Surg. 2014;53:320–335.

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