The Use Of Intravascular Ultrasonography In Transcarotid Artery Revascularization Optimizes Stent Placement

Transcarotid artery revascularization (TCAR) has been shown to have increasingly promising outcomes compared with transfemoral carotid artery stenting and carotid artery endarterectomy. At present, the standard practice is to obtain two two-dimensional angiographic views separated by 90° to evaluate stent deployment. Suboptimal stent deployment, poor stent apposition, or residual vessel stenosis are potential factors that can poorly affect the outcome. Postdilatation angioplasty can often correct these issues; however, it can be associated with a greater risk of embolic events. Two-dimensional angiography alone has limitations. We studied the usage of intravascular ultrasonography (IVUS) as an adjunct in evaluating carotid stent deployment and identifying the need for postdilatation intervention. A retrospective two-institution review was completed to identify all patients who had undergone TCAR during a 2-year period from January 2019 to January 2021. Only TCARs using IVUS were included. The patient demographics, lesion characteristics, and operative characteristics were extracted. Between January 2019 and January 2021, 19 TCAR procedures using IVUS had been performed at our institution. Of these 19 patients, 13 (68.4%) were men, with a median age of 72 years. Of the 19 patients, 9 (47.4%) had been treated for symptomatic stenosis. The average lesion length was 29.8 mm (Table I). The average procedure time was 136.5 minutes, with an average fluoroscopy time of 10.2 minutes and average flow reversal time of 32.9 minutes. Postdilation angioplasty was performed in 8 patients (42.1%), whose angiography demonstrated acceptable or equivocal findings but significant residual stenosis on IVUS (Table II). Technical success was achieved in 100% (19 of 19 patients). No perioperative myocardial infarction, stroke, transient ischemic attack, or death occurred. The use of IVUS in conjunction with TCAR might facilitate the evaluation of carotid stent deployment. Although the use of IVUS increased the procedural times, no related procedural complications occurred. IVUS is a safe and useful adjunctive tool and should be considered for carotid stenting procedures.Table ICharacteristics of patients undergoing TCAR with IVUSCharacteristicIVUS with TCAR (n = 19)Age, years72 (68-76.5)Male sex13 (68.4)Comorbidity Coronary artery disease8 (42.1) Hyperlipidemia14 (73.7) Hypertension16 (84.2) Smoker8 (42.1)Lesion characteristics Symptomatic9 (47.4) LateralityRight13 (68.4)Left6 (31.6) Primary involvement Common carotid artery7 (36.8) Bifurcation7 (36.8) Internal carotid artery17 (89.5) Lesion length, mm29.8 Percentage of stenosis <70%1 (5.3) 70%-80%5 (26.3) 80%-90%7 (36.8) >90%6 (31.6)IVUS, Intravascular ultrasound; TCAR, transcarotid artery revascularization.Data presented as number (%), unless noted otherwise. Open table in a new tab Table IIOperative characteristics of patients undergoing TCAR with IVUSOperative characteristicsIVUS with TCAR (n = 19)Average flow reversal time, minutes32.9Average fluoroscopy time, minutes10.2Average procedure time, minutes136.5Predilatation angioplasty, no. (%)19 (100)Postdilatation angioplasty, no. (%)8 (42.1)IVUS, Intravascular ultrasound; TCAR, transcarotid artery revascularization. Open table in a new tab