Concomitant Carotid Endarterectomy and Retrograde Carotid Artery Stenting is Safe and Effective for the Treatment of Tandem Carotid Artery Lesions

Data regarding the treatment of tandem carotid artery lesions at the bifurcation and ipsilateral, proximal common carotid artery (CCA) are limited. It has been suggested that concomitant treatment with carotid endarterectomy (CEA) and proximal retrograde carotid artery stenting (rCAS) confers a high risk of stroke and death. The objective of this study was to evaluate the technique and outcomes of this hybrid procedure at a single institution. Retrospective chart review was performed including patients who underwent CEA + rCAS for treatment of atherosclerotic carotid artery disease between December 2007 and April 2017. Primary end points were postoperative myocardial infarction (MI), neurologic event, and perioperative mortality. Twenty-three patients (15 male [65%]) underwent CEA + rCAS with a mean follow-up of 2.7 ± 2.5 years. The mean age was 70.9 ± 5.8 years, all with prior smoking history (nine current [39%]). Thirteen patients (57%) were treated for symptomatic disease, and four had a previous ipsilateral CEA (one also with CAS). Computed tomography angiography imaging was performed preoperatively in 22 patients (96%). CEA was performed first in 19 (83%) patients followed by rCAS. CEA was performed with a patch in 21 and eversion endarterectomy in 2 patients. Ipsilateral CCA was stented in 22 patients (96%), and one innominate was stented in a patient with a right CEA. Additional endovascular interventions were performed in three patients: one innominate stent, one distal ipsilateral internal carotid artery stent, and one right subclavian artery stent. All proximal stents were placed retrograde, with sheath access through the patch in 13 (57%), CCA in 7 (30%), and arteriotomy before patch in 3 (13%). Distal clamping was performed in 22 (96%) patients before rCAS. All proximal lesions were successfully treated endovascularly with no open conversion for treatment of proximal lesions. Two dissections were created, one stented and the other treated medically without complication. There was one perioperative stroke (4.3%) in a patient treated for symptomatic stenosis, one postoperative MI (4.3%), and cranial nerve injuries in two (8.7%) patients. There was one 30-day death after discharge. Concomitant CEA + rCAS can be safely performed in high-risk patients with low risk of MI, neurologic events, and perioperative mortality when careful surgical technique is employed, using direct carotid access and distal carotid clamping for cerebral protection before stenting.