Transient flow reversal combined with sustained embolic prevention in transcervical revascularization of symptomatic and highly-emboligenic carotid stenosis for optimized endovascular lumen reconstruction and improved peri- and post-procedural outcomes

Introduction

Several fundamental advancements have been developed both in embolic protection systems and in technical approaches to reduce the perioperative stroke rates associated with carotid stenting [1–6]. Those developments have been recently reinforced by the progress in carotid stent design [7] that today allows to effectively sequestrate the atherosclerotic plaque, minimizing intra-procedural and preventing post-procedural embolism (second-generation carotid stents, mesh-covered stents) [8]. Transcervical carotid artery stenting under transient flow reversal is a surgical technique that entered its clinical use nearly 2 decades ago [3–5]. Recently, the technique has gained a new momentum with an accumulating data-based realization of its two fundamental advantages: (1) robust cerebral protection by flow reversal is operational against embolism even prior to any endovascular approach to the lesion (i.e., ‘protected’ lesion crossing), is continuous, and is highly effective throughout the procedure, and (2) avoiding cerebral embolism associated with aortic arch cannulation [3–5, 9]. Accumulating results from transcarotid artery revascularization (TCAR, using the EnRoute flow reversal system, Silk Road) studies show low stroke/death rates comparable to carotid endarterectomy while maintaining the minimally invasive benefits of carotid stenting [10, 11]. The transcervical approach, which circumvents a number of embolic-risk maneuvers inherent to transfemoral carotid stenting, and with its highly effective proximal cerebral protection [9], has a strong potential to become, in surgical hands at least (as the system requires surgical, rather than percutaneous, exposure of the common carotid artery, CCA), the preferred method of carotid artery stenting (CAS) in the near future. Paired with the progress in carotid stent technology [7, 12], it may well challenge carotid endarterectomy (CEA) as the carotid artery revascularization method of choice not only in standard-risk lesions, but also in symptomatic and highly emboligenic lesions [11]. Our experience, over the years, involved a high-proportion proximal cerebral protection use [6, 13–15] and it also involved our introduction [16] and every-day clinical practice all-comer patient-and-lesion evaluation [15–17] of the MicroNET-covered embolic prevention stent. As an International ‘TCAR Center of Excellence’ (2018) we systematically paired the TCAR system (EnRoute, Silk Road) with our routine...


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