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Comment & Response
February 5, 2020

Transcarotid Artery Revascularization With Flow Reversal—Reply

Author Affiliations
  • 1Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
JAMA Surg. Published online February 5, 2020. doi:10.1001/jamasurg.2019.5445

In Reply We appreciate the interest in and commentary on our published systematic review1 of management and timing of intervention in patients presenting with crescendo transient ischemic attacks (cTIA).1 We agree with Paraskevas that the results from prospective2,3 and retrospectives studies4-6 suggest that transcarotid artery revascularization (TCAR) may be a revolutionary and durable carotid option for patients with some types of symptomatic presentation, such as TIA. However, data supporting TCAR have excluded patients with more urgent presentations, such as cTIA. For example, in the pivotal Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) trial,2 patients with unstable neurological symptoms, such as cTIA, were excluded. In the retrospective study by Kashyap et al6 and retrospective studies of the Vascular Quality Initiative database,4,5 it is not possible to ascertain whether and which patients presented with cTIA. Therefore, the safety of TCAR in patients with acute cerebral ischemia is not yet established; larger studies with more granular data are needed to confirm the safety of TCAR in this specific patient population.

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