Risk Factors and Consequences of Bleeding Complications after Transcarotid Artery Revascularization in the Vascular Quality Initiative.

Background: Previous case series on postoperative bleeding complications after transcarotid artery revascularization (TCAR) have primarily been through case series. The purpose of this study is to evaluate risk factors and consequences of bleeding complications after TCAR on a national level.

Methods: The Vascular Quality Initiative database was retrospectively queried for all patients undergoing TCAR between 2017 and 2023. The primary outcome of interest was postoperative bleeding complications, which included all neck hematomas, surgical bleeding, and pseudoaneurysms. Univariate tests and multivariable logistic regression analyses were utilized.

Results: A total of 50,909 TCAR procedures were included. The overall incidence of bleeding complications was 1.9%. The strongest risk factor for postoperative bleeding complications was lack of intraoperative protamine (adjusted odds ratio [aOR] 3.91 [95% confidence interval [CI], 3.41-4.47], P < 0.0001). Other risk factors included prior carotid endarterectomy (aOR 1.44 [95% CI, 1.18-1.75], P = 0.0004), neck radiation (aOR 1.42 [95% CI, 1.08-1.85], P = 0.01), and symptomatic stenosis (aOR 1.19 [95% CI, 1.04-1.35], P = 0.009). Preoperative and discharge anticoagulants (AC) were not associated with bleeding complications. Patients suffering postoperative bleeding complications had a longer index hospitalization and more unplanned reoperations for bleeding (P < 0.0001 both). Nonbleeding complications were also more common among patients suffering bleeding complications, including cranial nerve injury, postoperative stroke, reperfusion injury, myocardial infarction, dysrhythmia, carotid stenosis or occlusion, congestive heart failure exacerbation, and wound infection (P < 0.0001 each).

Conclusion: Postoperative bleeding complications are rare after TCAR and may be associated with adverse outcomes, including systemic and neurologic sequelae. Bleeding complications are not associated with AC or antiplatelet regimen. However, intraoperative protamine is associated with reduced risk of surgical bleeding complications, and should be considered during TCAR operations.