Management and Treatment of Tandem Carotid Lesions.

Background: Tandem lesions of the proximal aortic branch vessels and carotid bifurcation are uncommon. While management strategies vary, a hybrid approach of carotid endarterectomy with retrograde common carotid artery (CCA) or innominate artery (IA) stenting has become a mainstay of treatment. The purpose of this article was to provide a review of the literature, discuss alternative treatment modalities, and highlight technical considerations of the hybrid approach.

Methods: We performed a systematic review of the literature by searching relevant key words in the Cochrane Library, PubMed/Medline, and Embase. The primary endpoints of this study were stroke and all-cause mortality at 30 days. Secondary outcomes included rate of technical success, re-stenosis and need for re-intervention, and stroke and all-cause mortality at 1 year.

Results: We identified 15 retrospective cohort studies with a cumulative 242 patients who underwent hybrid repair. The average technical success rate of hybrid repair for the management of tandem carotid lesions was high (98.8%). Multiple studies reported zero events. The average 30-day mortality rate across all studies was 0.6% (pooled: 3/242, 1.2%) and average 30-day stroke rate across all studies was 0.9% (pooled: 7/242, 2.9%). Of the studies that reported rates of re-stenosis and need for re-intervention, the average re-stenosis rate was 9.6% (pooled 34/209; 16.3%). The most common area of re-stenosis was the proximal carotid CCA/IA (61.7%). The average reintervention rate across all studies was 4.5% (pooled 13/209; 6.2%).

Conclusions: A hybrid approach of carotid endarterectomy with retrograde CCA/IA stenting is a safe and effective treatment modality for tandem carotid disease. However, there remains a paucity of high-level data as single-center studies are subject to publication bias. This study highlights the critical need for a prospective registry to prognosticate the risk of stroke and mortality for patients with asymptomatic versus symptomatic tandem carotid lesions.