Importance

Carotid endarterectomy is associated with lower risk of perioperative stroke compared to transfemoral carotid artery stenting in the treatment of carotid artery stenosis. However, there is discrepancy in data regarding long-term outcomes. We aimed to compare long-term outcomes of carotid endarterectomy vs transfemoral carotid artery stenting using the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database.

Methods

We assessed patients undergoing first-time carotid endarterectomy or transfemoral carotid artery stenting in VQI-VISION from January 2003 to December 2018. Patients with prior history of carotid revascularization, non-transfemoral stenting, stenting performed without distal embolic protection, multiple or non-atherosclerotic lesions, or concomitant procedures were excluded. The primary outcome of interest was all-cause mortality, any stroke, and combined endpoint of death or stroke. We additionally performed propensity score matching and stratification based on symptomatic status.

Results

A total of 80,146 carotid revascularizations were performed of which 72,615 were carotid endarterectomy and 7,531 were transfemoral carotid artery stenting. CEA was associated with significantly lower risk of death (57.8% vs. 70.4%, aHR 0.46, 95%CI 0.41-0.52, p<0.001), stroke (21.3% vs. 26.6%, aHR 0.63, 95%CI 0.57-0.69, p<0.001) and combined endpoint of death and stroke (65.3% vs. 76.5%, HR 0.49, 95%CI:0.44-0.55, p<0.001) at 10 years. These findings were reflected in the propensity-matched cohort (combined endpoint: 34.6% vs. 46.8%, HR 0.53, 95%CI: 0.46-0.62) at 4 years as well as stratified analyses of combined endpoint by symptomatic status (asymptomatic: 63.2% vs. 74.9%, HR 0.49, 95%CI: 0.43-0.58, p<0.001; symptomatic 69.9% vs. 78.3%, HR 0.51, 95%CI: 0.45-0.59, p<0.001) at 10 years.

Conclusions

In this analysis of North American real-world data, CEA was associated with greater long-term survival and fewer strokes compared to TFCAS. These findings support the continued use of CEA as the first-line revascularization procedure.

Background

While Transfemoral Carotid Artery Stenting (TFCAS) is a valid minimally invasive option for patients who also might be suitable for carotid endarterectomy (CEA) or transcarotid artery revascularization (TCAR), alternative access sites such as transbrachial (TB) or transradial (TR) are only utilized when anatomic factors preclude direct carotid or transfemoral access. In this study, we aimed to evaluate the outcomes of TR/TB access in comparison to TF for percutaneous carotid artery revascularization.

Methods

All patients undergoing non-TCAR carotid artery stenting (CAS) from January 2012 to June 2021 in the Vascular Quality Initiative (VQI) Database were included. Patients were divided into 2 groups based on the access site for CAS: TF or TR/TB. Primary outcomes included stroke/death, technical failure and access site complications (hematoma, stenosis, infection, pseudoaneurysm and AV fistula). Secondary outcomes included stroke, TIA, MI, death, non-home discharge, extended length of postoperative stay (LOS) (>1 day), and composite endpoints of stroke/MI and stroke/death/MI. Univariable and multivariable logistic regression models were used to assess postoperative outcomes, and results were adjusted for relevant potential confounders including age, gender, race, degree of stenosis, symptomatic status, anesthesia, comorbidities, and preoperative medications.

Results

Out of the 23,965 patients, TR/TB approach was employed in 819 (3.4%) while TF was used in 23,146 (96.6%). Baseline characteristics found men were more likely to undergo revascularization using TR/TB approach (69.4% vs. 64.9%, P = 0.009). Patients undergoing TR/TB approach were also more likely to be symptomatic (49.9% vs. 28.6%, P < 0.001). Guideline directed medications were more frequently used with TR/TB including P2Y12 inhibitor (80.3% vs. 74.7%, P < 0.01), statin (83.8% vs. 80.6%), and aspirin (88.3% vs. 84.5%, P = 0.003) preoperatively. On univariate analysis, patients with TB/TR approach experienced higher rates of adverse outcomes. After adjusting for potential confounders, TR/TB patients had no significant increase in the risk of stroke/death [aOR 1.10 (0.69-1.76), P = 0.675]; however, the use of TR/TB access was associated with a more than 2-fold increase in risk for in-hospital MI [aOR 2.39 (1.32-4.30), P = 0.004] and 2-fold increase in risk of technical failure [aOR 2.21 (1.31-3.73) P = 0.003]. The use of TR/TB access was also associated with a 50% reduction in the risk of access site complications [aOR 0.53 (0.32-0.85), P = 0.009].

Conclusions

This study confirms that although technically more challenging, TR or TB approach serves as a reasonable alternative with lower access site complications for CAS particularly in patients where anatomic factors preclude revascularization by TFCAS or TCAR. However, TR/TB is associated with an increased risk of technical failure and myocardial infarction, which requires further study.