Transcervical carotid artery stenting (CAS) has emerged as an alternative to transfemoral CAS. An earlier systematic review from our group (n = 12 studies; 739 transcervical CAS procedures [489/739 with flow reversal]) demonstrated that transcervical CAS is a safe procedure associated with a low incidence of stroke and complications. Since then, new studies have been published adding nearly 1,600 new patients to the literature. We aimed to update our early systematic review and also to perform a meta-analysis to investigate outcomes specifically after transcervical CAS with flow reversal.
An electronic search of PubMed/Medline, Embase, and the Cochrane databases was carried out to identify studies reporting outcomes after transcervical CAS with flow reversal. Crude event rates for outcomes of interest were estimated by simple pooling of data. A proportion meta-analysis was also performed to estimate pooled outcome rates.
A total of 18 studies (n = 2,110 transcervical CAS procedures with flow reversal) were identified. A high technical success (98.25%) and a low mortality rate (0.48%) were recorded. The crude rates of major/minor stroke, transient ischemic attack (TIA) and myocardial infarction were 0.71%, 0.90%, 0.57% and 0.57%, respectively, while a cranial nerve injury occurred in 0.28% of the procedures. A neck hematoma was reported in 1.04% of the procedures, a carotid artery dissection occurred in 0.76% of the interventions, while in 1.09% of the cases conversion to carotid endarterectomy was required. After undertaking a meta-analysis, the pooled technical success rate was 98.69% (95% confidence interval [CI]: 97.19-99.70). A pooled mortality rate of 0.04% (95% CI: 0.00-0.29) was recorded. The pooled rate of any type of neurological complications was 1.88 (95% CI: 1.24-2.61), while the pooled rates of major/minor stroke and TIA were 0.12% (95% CI: 0.00-0.46), 0.15% (95% CI: 0.00-0.50) and 0.01% (95% CI: 0.00-0.22), respectively. The pooled rate of bradycardia/hypotension was 10.21% (95% CI: 3.99-18.51), whereas the pooled rate of MI was 0.08% (95% CI: 0.00-0.39). A neck hematoma after transcervical CAS was recorded in 1.51% (95% CI: 0.22-3.54) of the procedures, while in 0.74% (95% CI: 0.05-1.95) of the interventions, conversion to CEA was required. Finally, a carotid artery dissection during transcervical CAS occurred in 0.47% (95% CI: 0.00-1.38) of the procedures.
This updated systematic review and meta-analysis demonstrated that transcervical CAS with flow reversal is associated with high technical success, almost zero mortality and very low major/minor stroke, myocardial infarction and complication rates.

Copyright © 2020. Published by Elsevier Inc.