Transcarotid artery revascularization for the management of blunt cerebrovascular injuries-is it a game changer?

In their 10 patient case series, Walker et al, describe excellent outcomes from the use of transcarotid artery revascularization (TCAR) for the treatment of patients with severe blunt cerebrovascular injuries (BCVI).1Dr. Patrick Walker et al. Transcarotid Artery Revascularization in Blunt Carotid Injury. J Vasc Surg Cases Innov Tech. 20XX, 1(1), XX-XX. doi: XXXX.Google Scholar. For a single center over only 2 years this is a large cohort for a relatively rare problem. It is important to note that the primary treatment for BCVI is antithrombotic therapy with antiplatelets and/or anticoagulation. It has been shown that transfemoral carotid artery stenting for BCVI is rarely necessary or beneficial over antithrombotic therapy and the EAST guidelines recommend against routine stenting of grade II or III BCVI.(2)Burlew C.C. Biffl W.L. Moore E.E. Pieracci F.M. Beauchamp K.M. Stovall R. Wagenaar A.E. Jurkovich G.J. Endovascular stenting is rarely necessary for the management of blunt cerebrovascular injuries.J Am Coll Surg. 2014; 218: 1012-1017https://doi.org/10.1016/j.jamcollsurg.2014.01.042Crossref PubMed Scopus (45) Google Scholar,(3)Kim D.Y. Biffl W. Bokhari F. Brakenridge S. Chao E. Claridge J.A. Fraser D. Jawa R. Kasotakis G. Kerwin A. et al.Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma.J Trauma Acute Care Surg. 2020; 88: 875-887https://doi.org/10.1097/TA.0000000000002668Crossref PubMed Scopus (32) Google Scholar The Denver group found an alarmingly high 45% occlusion rate in patients treated with stenting vs. only 5% in those treated with antithrombotic therapy and concluded that stenting for BCVI had an unacceptable risk profile.(4)Cothren C.C. Moore E.E. Ray C.E. Ciesla D.J. Johnson J.L. Moore J.B. Burch J.M. Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits.Arch Surg. 2005; 140 (; discussion 485-486): 480-485https://doi.org/10.1001/archsurg.140.5.480Crossref PubMed Scopus (111) Google Scholar It seems clear that stenting is rarely indicated for BCVI and this is consistent with the experience of the Maryland Shock Trauma study, as the authors point out that their center diagnoses approximately 300 carotid BCVIs per year, of which only 2-3% were selected for TCAR. It's possible that TCAR may be associated with a lower stroke and complication rate in BCVI patients in a similar manner to its benefits for carotid occlusive disease. Namely, by the use of dynamic flow reversal, which was found by Naazie, et al. in their Vascular Quality Initiative study to be the primary mechanism for stroke protection in TCAR.(5)Naazie I.N. Magee G.A. Mathlouthi A. Elsayed N. Dakour-Aridi H. Malas M.B. Primary mechanism of stroke reduction in transcarotid artery revascularization is dynamic flow reversal.J Vasc Surg. 2021; 74: 187-194https://doi.org/10.1016/j.jvs.2020.10.082Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Although the focus of this series is on the novel use of TCAR in the setting of BCVI requiring stenting, the authors describe another innovation, which is the use of Supera stents (Abbott, Plymouth, MN). The authors state that they prefer Supera stents for this application because of its flexibility and length, as they often stent up to the skull base to treat the entirety of the injury. At first glance, this seems to be an usual choice, but their results suggest that the authors may be on to something. Further study is necessary to determine if TCAR is a gamechanger for the management of BCVI and which of these two innovations is the primary reason for improved outcomes. Transcarotid Artery Revascularization in Blunt Carotid InjuryJournal of Vascular Surgery Cases, Innovations and TechniquesPreviewTranscarotid artery revascularization (TCAR) with flow reversal has substantially changed the management of carotid artery stenosis, enabling an endovascular approach with a periprocedural stroke rate as low or lower than that of open carotid surgery. The use of TCAR in blunt carotid injury has not yet been described. Full-Text PDF Open Access