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| But if transfemoral stenting is more successful, do you think that's more likely coming out of open or is there a possibility some of that comes from TCAR if you would think theoretically? Chas McKhann Yeah, no, I think we do see a world that over time becomes more endovascular based, right, and we certainly expect that TCAR is very well positioned to capture the majority of that growth and that as I said, Silk Road Medical is well positioned to capture and continue to be the leader in treatment of CAD, right? We know the space really well and we've got a level of commitment to it that others just don't have |
| But we are already seeing that these additions to our team are strengthening their relationships and growing their case volumes across the physicians and staff they serve |
| At the same time, we are committed to driving sustainable progress towards profitability, with a strong capital position and scaled infrastructure we have today |
| And so in sum, I am very excited about the year ahead |
| I feel really good about our ability to do that |
| And with our portfolio over 250 issued and pending patents globally and our core competence in transcarotid access and neuroprotection, we are well positioned to serve our stroke prevention mission and drive durable long-term growth |
| And TCAR stacks up really favorable when you consider all those variables at the hospital level |
| Silk Road is a world-class company with a world-class opportunity and we expect to capitalize on that opportunity for the betterment of patients and shareholders |
| TCAR works with incredible consistency, and the TCAR base of adoption is growing and healthy |
| The mood is good, the attitude is good, the excitement for the year is good |
| But I will tell you, we feel good about the people we hired |
| Our customers feel very good about the ongoing demand for TCAR |
| Growth was driven primarily by increased TCAR adoption and continued healthy demand, following expanded Medicare reimbursement, which went into effect October 11th of last year |
| And so just happy to see, as I mentioned, very good uptake with the balloon and nice progression there, having the tapered stent, and as I mentioned, and a pretty limited number of accounts initially, but very good feedback from customers |
| But we feel good about the overall health there |
| In combination with our modest burn profile, we remain confident in our ability to achieve profitability with existing capital |
| And so we do expect to have another year of improvement on that important metric as well sitting here with our $191 million of cash on the balance sheet |
| Today, our team is as strong as ever, following initiatives we took last year to optimize our commercial model and to achieve greater scale and continue to evolve from going broad to going deep |
| At this point in my career, it's all about delivering excellent patient outcomes, supporting an unmatched provider experience, and contributing to a better healthcare system |
| But as we think about overall on the guidance and kind of key puts and takes that went into it, first and foremost, I hope you heard me loud and clear of feeling very good about the overall fundamentals of the market and where we can take things |
| The outstanding clinical outcomes for TCAR are a testament to the excellent support that our team provides to our customers every single day |
| Beyond the right commercial infrastructure, deepening adoption requires we continuously innovate on our key product lines to extend our leadership position in carotid treatment and enhance the offerings for TCAR |
| We're going to keep watching it incredibly carefully, but as the only company that really is dedicated to this space, we feel good about our ability to keep driving demand for TCAR in a world that over time will move to be more endovascular, but we think that we're well positioned for that |
| We are pleased with the outcomes of this early feasibility study, which showed that transcarotid acute stroke thrombectomy with flow reversal is feasible and safe |
| Our expectation is for adjusted EBITDA improvement in the full year 2024 relative to 2023 |
| And we are targeting annual improvement in adjusted EBITDA in 2024 relative to 2023, building off our progress in recent years |
| I'm pleased to share that Silk Road Medical achieved full year 2023 revenue of just over $177 million, supported by more than 25,250 procedures, reflecting 28% and 29% year-over-year growth in revenue and procedures respectively |
| In 2024, we anticipate full year revenue of $194 million to $198 million, reflecting 10% to 12% year-over-year growth, as we capitalize on the strength of our commercial infrastructure to drive deeper adoption among our active physician base |
| Cultivating international markets offers an extension of TCAR growth in the long term |
| And so with these strong fundamentals I've outlined, our focus in 2024 is optimizing the transition from broadening our reach to now deepening adoption among our trained physician base, while recognizing and improving leverage that comes with scaled operations |
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| And in particular, prior treatment modalities for patients with carotid artery disease fall short of addressing the issue |
| We had some attrition |
| Patients historically choose -- historically chose between carotid endarterectomy, an invasive surgical procedure with significant patient morbidity and procedure-related complications, or transfemoral carotid stenting, a minimally invasive approach in which procedural difficulty and lack of effective neuroprotection can lead to excess procedure-related stroke risk |
| Adjusted EBITDA for the fourth quarter, 2023, was a loss of $4.1 million compared to an adjusted EBITDA loss of $4.4 million in the prior year period |
| However, note that we expect our first quarter 2024 adjusted EBITDA loss to be larger than the loss we saw in the fourth quarter of 2023, given standard first quarter expenses against an expectation for a mid-single-digit sequential revenue decline related to seasonal patterns |
| Net loss for the fourth quarter was $13 million or a loss of $0.33 per share as compared to a net loss of $12.6 million or a loss of $0.34 per share for the same period of the prior year |
| So I think carrying forward the Q4 result into Q1 is probably not the right approach because we do see and expect kind of that normal dip in revenue per procedures, even if procedures are strong |
| The learning curve with TCAR is slow, the adoption, I mean it's fast, the learning curve is quick |
| As a reminder, we recognize revenue when we sell units to hospitals, and those hospital-owned inventory units are later used by physicians and procedures, leading to some quarter-to-quarter variation in revenue growth relative to procedure growth |
| Frank, we're not seeing that |
| I know you talked about how you expect kind of the forward OpEx growth to be lower than sales growth |
| And it really is a variety of factors that impacted that |
| First, the deficiency in current carotid treatment is indisputable when we look at the devastating burden of stroke on patients and their families |
| I think, as I was going through my interviews and process last year, you had a little bit of sort of this feeling that somehow there was this wave that was going to happen |
| And so the variability we're talking about does have to do with things like order patterns |
| The consequences of stroke by the numbers are staggering |
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