A systematic review and meta-analysis of combined carotid endarterectomy with ipsilateral proximal intervention (the hybrid approach) for tandem carotid artery lesions.

Abstract Objective The safety and effectiveness of using the hybrid approach to treat tandem carotid lesions is controversial, and the clinical significance of technical variants on perioperative outcomes has not been evaluated. This meta-analysis was performed to evaluate the technique, safety, effectiveness and long-term outcomes of the hybrid approach. Methods The PubMed, Embase and Cochrane Library databases were searched to identify studies from January 1, 1996 to January 11, 2020. Baseline patient characteristics, comorbidities, procedural details, and perioperative and long-term outcomes were collected and analyzed. A pooled overall survival curve was drawn. Univariate analysis was performed to compare perioperative stroke risk between subgroups. Results Overall, 275 patients (mean age, 66.94 years) from 15 studies were included. All patients presented with tandem stenosis ≥50%, and 67.2% of them were symptomatic. The overall technical success rate was 99.8% (95% confidence interval [CI], 98.0%-100.0%). The pooled perioperative complications rates were as follows: death, 1.5% (95% CI, 0.0%-2.9%); stroke, 2.6% (95% CI, 0.7%-4.4%); combined stroke/death, 3.3% (95% CI, 1.2%-5.4%); and myocardial infarction, 3.2% (95% CI, 0.7%-9.1%). Overall primary patency rates were 99.2% (95% CI, 96.0%-100.0%) and 88.2% (95% CI, 78.8%-95.4%) at 1 and 2 years, respectively. Reintervention was performed in 6.6% (95% CI, 3.0%-11.2%) of patients. Pooled overall survival rates were 89.9% (95% CI, 83.7%-96.7%), 83.7% (95% CI, 75.9%-92.2%), and 75.9% (95% CI, 66.5%-86.7%) at 1, 3, and 5 years, respectively. Operations in which carotid endarterectomy (CEA) was performed first carried a significantly higher risk of perioperative stroke than those in which proximal intervention was performed first (5.7% versus 0.0%; P = 0.01). There was no difference in perioperative stroke risk between subgroups of baseline symptomatic status (asymptomatic, 5.1%; symptomatic, 1.9%; P =0.32), preoperative antiplatelet therapy (dual, 3.6%; single, 5.8%; P =0.79), and carotid clamping during intervention (clamping, 2.8%; unclamping, 6.3%; P = 0.40). Conclusions For patients with a presumed high risk of neurological events due to carotid tandem lesions, the hybrid approach could be considered as a reasonable option with high technical success and acceptable perioperative and long-term results. Performing carotid artery stenting prior to CEA and administering perioperative dual antiplatelet therapy should be considered to promote technical success and better outcomes. Prospective and randomized controlled studies are needed to confirm the results and provide a recommendation on patient selection for the hybrid approach.