No difference found in TCAR outcomes between academic and community hospitals

New study found no difference in perioperative outcomes and incidence of adverse events at follow-up after transcarotid artery revascularization (TCAR) between academic and non-teaching community institutions. Presented at the 2023 winter annual meeting of the Vascular and Endovascular Surgery Society (VESS) in Whistler, British Columbia (Feb. 23–26), lead authors Samuel Leonard, MD, and Shihuan K. Wang, MD, of UTHealth in Houston, Texas, spoke to Vascular Specialist and situated their research within contemporary vascular practice.

Outlining their two-pronged research aim, Leonard began by elucidating their initial objectives, noting that they wanted to compare patient cohorts between community versus academic hospitals, as well as outcomes in patients who underwent TCAR at these institutions.

Building on this, Wang explained the relatively recent and “[quick]” adoption of TCAR—after the Food and Drug Administration’s (FDA) approval of reverse flow carotid stenting in 2015—which has influenced an “exponential” rise in the volume of TCAR procedures being carried out, he asserted. Due to wider availability, Wang continues, TCAR is no longer limited to academic institutions but is being performed in smaller hospitals, setting the stage for the investigation the authors conducted.

The researchers carried out a retrospective review of prospectively maintained system-wide databases from

UTHealth, Houston, and IU Health, Indianapolis, Indiana, evaluating TCAR procedures performed between 2015–2022.

Patients were stratified based on the setting of surgical intervention, such as academic with trainees or non-teaching community hospital with only staff surgeons. Relevant demographics, medical conditions, anatomical characteristics, intra- and post-operative courses, and adverse events were captured for statistical analysis.

Identifying 729 patients who underwent TCAR, the authors found no significant difference in perioperative stroke at 30-day follow-up, however, they did note disparities in performance metrics between institutions. Procedures carried out at academic hospitals took longer, although Leonard points out that this may be attributable to the complexity level of the cases they receive.

Nonetheless, the “comparable” results for TCAR, regardless of care location, show that you do not necessarily need the “big box of resources” to have desirable outcomes, as Wang phrased it.

“We’re not saying everyone should be getting [TCAR], we certainly don’t have the data for that”—both authors agreed that advocation is not their intent—”the gold standard continues to be carotid endarterectomy (CEA),” Wang clarified.

Additionally, when recalling the questions put to the authors at VESS 2023, Leonard posited that their advocacy for TCAR was tangibly “on the audience’s mind,” reiterating that the investigators continue to abide by the Society for Vascular Surgery (SVS) guidelines, which continue to recommend CEA for carotid disease.

Quashing any hint of upheaval, the absence of any industry supported trial or study evaluating TCAR data which shows clinical equipoise between TCAR and CEA, meant there “wasn’t too much uproar from the audience,” Leonard explained.

On a sobering note, Wang added: “It’s a new technology, there is limited evidence, and the pendulum is swinging toward TCAR a little too aggressively right now and I do worry about that.” Making clear that CEA still takes precedence, TCAR, he stated, will remain an “alternative” until clinical trials shed more light on its efficacy.

As Wang continued, he stated their results emphasize a broadening of resources, “opening up options” for patients, noting that particularly for elderly or very unwell patients, navigating a large academic hospital may not be feasible, and attending a smaller, local institution may be advantageous. “A lot of these patients prefer, if possible, to get procedures done at a smaller place that’s just as good, and then drive, two, three blocks away to the Big Mega Mart—this data reassures patients a little bit,” he said.

Echoing Wang’s sentiment, Leonard concluded by expressing their continued efforts to build the database to extract “other salient points” in the future.—Eva Malpass