Ultrasound examination without axial imaging is sufficient for pre-operative in planning transcarotid artery revascularization (TCAR).

OBJECTIVES: Duplex ultrasound is frequently used to determine the degree of carotid stenosis. However, axial imaging is typically obtained for operative planning for transcarotid artery revascularization (TCAR). We examined if ultrasound alone is sufficient prior to TCAR.

METHODS: Data from the Vascular Quality Initiative TCAR Surveillance Project registry between 2016 and 2021 was obtained. Patients were divided into two groups - those with preoperative ultrasound alone (US) versus those with additional axial imaging (AX). Peri-operative outcomes were compared utilizing univariate chi-square, independent t-test, multivariate logistic regression, and Kaplan Meier analysis.

RESULTS: There were 3,418 patients identified: 682 in the US group and 2,736 in the AX group. More pre-operative hypertension was reported in US (16.1% vs 10.2%, p<.001) while cardiovascular disease (23% vs 28.9%, p=.006) and prior ipsilateral stroke (22%,vs 32.7%, p=.002) were more prevalent in AX. More patients had history of contralateral carotid endarterectomy (13.6% vs 16.7%, p=.035) or either ipsilateral (2.6% vs 1.2%, p=.002) or contralateral (7.9% vs 4.9%, p=.008) carotid artery stenting in the US group. Lower pre-operative creatinine was reported in the US cohort (1.09±-0.01 vs 1.18±0.02, p<.001) while more were symptomatic in AX (28.2% vs 36.2%, p<.001). There were no significant differences between lesion characteristics or operative decision making were noted. A slightly higher total procedure time was seen in AX (73.7±0.6 vs 68.6±1.3 min, p=.017). No difference existed in peri-operative TIA/stroke or other immediate complications. At two-year follow-up, both groups reported no significant differences in stroke-free survival (p=.750) and independent functional status remained near-identical (97.3% vs 97.4%, p=.921). Kaplan Meier analysis yielded no significant difference between mortality at two years (p=.563). Bivariate logistic regression modeling did reveal a statistically significant increase in likelihood of long-term ipsilateral stroke/TIA at long-term follow-up (OR 1.77, p = .015) and non-stroke related complication in the post-operative period (OR 4.81, p = .005). However, only a statistically significant relationship persistent when the model was controlled for significant between-group differences.

CONCLUSIONS: No significant differences in post-operative or long-term complications were noted with additional axial imaging in pre-operative TCAR planning. Thus, duplex ultrasound offers a safe and effective alternative for those with contraindication or axial imaging.