Patient and Surgeon Decision-Making in the Era of Transcarotid Arterial Revascularization

Studies of transcarotid arterial revascularization (TCAR) primarily focus on quantitative outcomes. It is not known how patients eligible for both carotid endarterectomy (CEA) and TCAR decide between procedures, or how surgeons consider and present these options. This study attempted to better understand the comprehension and decision-making process of patients with carotid stenosis. We performed a qualitative study using longitudinal semistructured interviews to define the domains important to patients undergoing CEA or TCAR. We used purposive maximum variation sampling and included 18 patients. Interviews were conducted preoperatively, immediately postoperatively, and 30 days postoperatively. We concurrently conducted semistructured interviews of vascular surgeons. Interview data were coded and analyzed using inductive content analysis coding. Most patients expressed a preference to discuss all surgical options and decide on treatment together with their surgeon. Factors most important to patients were the surgeon’s experience with the procedure and the presence of long-term outcomes data. The size of the incision and length of the operation were frequently described as unimportant. Patients who preferred CEA felt the outcomes were superior to TCAR and often reported a desire to eliminate the carotid plaque. Patients who preferred TCAR expressed a desire for the newest, least invasive option with the shortest procedural and recovery time. Patients most frequently cited stroke, bleeding risk, size of scar, and longer procedure/recovery time as concerns with undergoing CEA. Concerns with TCAR included concern for leaving a foreign body or the plaque in the artery and a desire to protect stenting as a future option in case of restenosis after CEA (Table). Surgeon impressions of TCAR varied. Although some viewed it as an option equivalent or even preferable to CEA, others wanted more long-term data and reserve TCAR only for high risk or reoperative patients. Nearly all surgeons discuss both procedures with all eligible patients. Patients being considered for carotid revascularization expressed a strong desire to participate in the decision-making process. Although some patients prefer TCAR as the newest option with shorter recovery, others favor CEA as a proven strategy with known long-term results and physical plaque removal with no residual foreign body. Surgeon impressions vary, although most surgeons routinely mention both options to patients eligible for both procedures. Surgeons treating patients with carotid stenosis should prioritize shared decision-making to best align patient preferences and values with the chosen revascularization strategy.TableSelected quotes from participants in the current studyShared decision-making “We talked about the balance between what the safety of the procedure and what the benefits of the procedure were. And so there are a whole lot of elements in there. And we just, you know, together hit on what was the best benefit.” “It was really up to me. We discussed the alternatives, and then it was totally my decision.”Preference for carotid endarterectomy “I like the idea of cleaning the artery out and leaving nothing artificial inside.” “I went with the carotid endarterectomy because I felt they have done more of those than the other. I don’t mind trying new procedures but when it came to this procedure, I felt like they knew more about it. If I was older, like in my early 60s, I would have gone with the stent because its less invasive.”Preference for TCAR “..[TCAR] was, we felt, the safest for me and it’s a new procedure that was created for people my age.” “…he felt that they would both be equal, but he preferred [TCAR] because [carotid endarterectomy] took I think three and a half hours to do. Mine took about an hour and [my surgeon] was thrilled with the outcome.” “Obviously I would rather have the stent, it is easier and less invasive.” “…the TCAR just seemed a whole lot neater and you didn’t have to have this big slice in your neck and the whole artery opened up.”Reasons against carotid endarterectomy “I think what has me concerned about endarterectomy is just the possibility of blood leakage from the artery incision and the possibility of anything that’s loose being discharged up into the brain.”Reasons against TCAR “Well, I think, you know, stenting doesn’t necessarily get rid of the plaque.” “…with the carotid disease that I got, I mean, I could possibly have it when I get older and it would be more of a surgery if they put the stent in now. So I chose to have the surgery instead.” “I didn’t want a foreign object left inside, I wanted to get it cleaned out.”TCAR, Transcarotid arterial revascularization. Open table in a new tab