Comparison of Carotid Endarterectomy and Transcarotid Artery Revascularization in High Cervical Lesions.

Background: High cervical carotid lesions increase intraoperative complexity in carotid endarterectomy (CEA) due to the challenge in obtaining a clean distal clamp site. For these cases, transcarotid artery revascularization (TCAR) may offer an alternative. Our aim was to compare outcomes of CEA and TCAR in patients with high cervical lesions.

Methods: Demographics and outcomes of CEA and TCAR procedures were retrospectively captured at two high-volume institutions between 2003 and 2023. Patients with high cervical lesions, defined as target clamp sites above the C2 vertebra, were included. Patients were dichotomized according to surgical procedure. Univariate analysis was performed comparing baseline characteristics and outcomes in both groups at an α < 0.05.

Results: 2,250 patients were reviewed, of which 106 lesions (5%) were classified as above C2, of which 73 (69%) underwent TCAR and 33 (31%) underwent CEA. TCAR patients were more likely symptomatic, whereas CEA patients were more likely to have coronary artery disease. Perioperative (30-day) morbidity was similar (ipsilateral stroke was 2.7% vs. 6.1%, p=0.406, myocardial infarction was 1.4% vs. 0%, p=0.499, cranial nerve injury was 1.4% vs. 6.1%, p=0.406, and mortality was 1.4% vs. 0%, p=0.499). Operative time and estimated blood loss were higher with CEA (72.9 ± 31.8 minutes vs. 132.5 ± 53.2 minutes, p <0.001, and 47.1 ± 57.3 mL vs. 214.2 ± 285.7 mL, p < 0.001).

Conclusion: This retrospective study demonstrates similar outcomes between CEA and TCAR. However, TCAR was associated with a shorter operative time, suggesting that this may be an advantageous approach.