Association of Transcarotid Artery Revascularization vs Transfemoral Carotid Artery Stenting With Stroke or Death Among Patients With Carotid Artery Stenosis

Abstract

Importance: Several trials have observed higher rates of perioperative stroke following transfemoral carotid artery stenting compared with carotid endarterectomy. Transcarotid artery revascularization with flow reversal was recently introduced for carotid stenting. This technique was developed to decrease stroke risk seen with the transfemoral approach; however, its outcomes, compared with transfemoral carotid artery stenting, are not well characterized.

Objective: To compare outcomes associated with transcarotid artery revascularization and transfemoral carotid artery stenting.

Design, setting, and participants: Exploratory propensity score-matched analysis of prospectively collected data from the Vascular Quality Initiative Transcarotid Artery Surveillance Project and Carotid Stent Registry of asymptomatic and symptomatic patients in the United States and Canada undergoing transcarotid artery revascularization and transfemoral carotid artery stenting for carotid artery stenosis, from September 2016 to April 2019. The final date for follow-up was May 29, 2019.

Exposures: Transcarotid artery revascularization vs transfemoral carotid artery stenting.

Main outcomes and measures: Outcomes included a composite end point of in-hospital stroke or death, stroke, death, myocardial infarction, as well as ipsilateral stroke or death at 1 year. In-hospital stroke was defined as ipsilateral or contralateral, cortical or vertebrobasilar, and ischemic or hemorrhagic stroke. Death was all-cause mortality.

Results: During the study period, 5251 patients underwent transcarotid artery revascularization and 6640 patients underwent transfemoral carotid artery stenting. After matching, 3286 pairs of patients who underwent transcarotid artery revascularization or transfemoral carotid artery stenting were identified (transcarotid approach: mean [SD] age, 71.7 [9.8] years; 35.7% women; transfemoral approach: mean [SD] age, 71.6 [9.3] years; 35.1% women). Transcarotid artery revascularization was associated with a lower risk of in-hospital stroke or death (1.6% vs 3.1%; absolute difference, -1.52% [95% CI, -2.29% to -0.75%]; relative risk [RR], 0.51 [95% CI, 0.37 to 0.72]; P < .001), stroke (1.3% vs 2.4%; absolute difference, -1.10% [95% CI, -1.79% to -0.41%]; RR, 0.54 [95% CI, 0.38 to 0.79]; P = .001), and death (0.4% vs 1.0%; absolute difference, -0.55% [95% CI, -0.98% to -0.11%]; RR, 0.44 [95% CI, 0.23 to 0.82]; P = .008). There was no statistically significant difference in the risk of perioperative myocardial infarction between the 2 cohorts (0.2% for transcarotid vs 0.3% for the transfemoral approach; absolute difference, -0.09% [95% CI, -0.37% to 0.19%]; RR, 0.70 [95% CI, 0.27 to 1.84]; P = .47). At 1 year using Kaplan-Meier life-table estimation, the transcarotid approach was associated with a lower risk of ipsilateral stroke or death (5.1% vs 9.6%; hazard ratio, 0.52 [95% CI, 0.41 to 0.66]; P < .001). Transcarotid artery revascularization was associated with higher risk of access site complication resulting in interventional treatment (1.3% vs 0.8%; absolute difference, 0.52% [95% CI, -0.01% to 1.04%]; RR, 1.63 [95% CI, 1.02 to 2.61]; P = .04), whereas transfemoral carotid artery stenting was associated with more radiation (median fluoroscopy time, 5 minutes [interquartile range {IQR}, 3 to 7] vs 16 minutes [IQR, 11 to 23]; P < .001) and more contrast (median contrast used, 30 mL [IQR, 20 to 45] vs 80 mL [IQR, 55 to 122]; P < .001).

Conclusions and relevance: Among patients undergoing treatment for carotid stenosis, transcarotid artery revascularization, compared with transfemoral carotid artery stenting, was significantly associated with a lower risk of stroke or death.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Schermerhorn reported receipt of personal fees for provision of consultancy services from Silk Road Medical, Abbott, Cook, Endologix and Medtronic outside the submitted work. Dr Kashyap reported being a national coprimary investigator for the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTERII). Dr Motaganahalli reported other for provision of consultancy services from Silk Road Medical during the conduct of the study. Dr Malas reported being a site principal investigator for the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) and the ROADSTERI and ROADSTERII trials, a national primary investigator for the ROADSTERI long-term follow-up study, and being a proctor for TCAR. No other disclosures were reported.

Figures

Figure 1.. Trend in Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting in the Vascular Quality Initiative

Yellow shading indicates the trend during the study period.

Figure 2.. Kaplan-Meier Estimated Stroke or Death in Patients Undergoing Transcarotid Artery Revascularization or Transfemoral Carotid Artery Stenting

Median observation time for transcarotid artery revascularization was 286 days (interquartile range [IQR], 35 to 371), and for transfemoral carotid artery stenting was 294 days (IQR, 36 to 393; hazard ratio, 0.52 [95% CI, 0.41 to 0.66]; P<.001).