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J Am Coll Surg. 2019 Oct 22. pii: S1072-7515(19)32140-4. doi: 10.1016/j.jamcollsurg.2019.09.020. [Epub ahead of print]

Learning Curve for Surgeons Adopting Transcarotid Artery Revascularization Based on the Vascular Quality Initiative-Transcarotid Artery Revascularization Surveillance Project: Transcarotid Artery Revascularization.

Author information

1
Department of Surgery, Division of Vascular and Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Cleveland, OH. Electronic address: Vikram.kashyap@uhhospitals.org.
2
Department of Surgery, Division of Vascular and Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Cleveland, OH.
3
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
4
Department of Surgery, Division of Vascular and Endovascular Therapy, Maine Medical Center, Portland, ME.
5
Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA.
6
Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, CA.
7
Section of Vascular Surgery and The Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Abstract

OBJECTIVE:

Transcarotid artery revascularization (TCAR) with flow reversal was recently introduced as a novel technique for carotid artery stenting (CAS). We examined the learning curve of surgeons adopting TCAR based on data from the Vascular Quality Initiative (VQI-TCAR Surveillance Project; TSP).

METHODS:

We identified all patients in the TSP who underwent TCAR from September 2016 to December 2018. Cases were numbered in chronological order for each unique surgeon. Patients were then divided into four levels based on surgeon case number for comparison: case 1-5 (novice), case 6-20 (intermediate), case 20-30 (advanced), and case >30 (expert).

RESULTS:

During the study period, 3,456 TCAR procedures were performed by 417 unique surgeons from 178 centers. Of all procedures, 1,426 (41%) were performed at the novice level, 1,375 (40%) at the intermediate level, 307 (8.9%) at the advanced level, and 348 (10%) at the expert level. Cases performed at more advanced levels had lower operative time (novice 82 vs intermediate 73 vs advanced 62 vs expert 60 mins, P < .001), fluoroscopy time (7 vs 6 vs 5 vs 5 mins, P < .001), and flow reversal time (12 vs 11 vs 10 vs 10 mins, P < .001). Cases done at more advanced levels had decreases in bleeding (3.9 vs 3.4 vs 1.6 vs 1.2%, P = .03). No differences in major in-hospital outcomes were found regardless of experience level including stroke (P = .99), death (P = .39), and composite stroke/death/myocardial infarction (P = .84).

CONCLUSIONS:

TCAR is being performed with excellent stroke and mortality rates in the TSP even in the early stages of the surgeons' learning curve. Bleeding complications, operative, fluoroscopy and flow reversal times all decrease with increasing TCAR experience.

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