UC San Diego

Objective

Carotid endarterectomy (CEA) remains the gold standard procedure for carotid revascularization. Transfemoral carotid artery stenting (TFCAS) was introduced as a minimally invasive alternative procedure in patients who are at high risk for surgery. However, TFCAS was associated with increased risk of stroke and death compared to CEA.

Summary background data

Transcarotid artery revascularization (TCAR) has outperformed TFCAS in several prior studies and has shown similar perioperative and one-year outcomes compared to CEA. We aimed to compare the one-year and three-year outcomes of TCAR vs. CEA in the Vascular Quality Initiative (VQI)-Medicare-Linked (Vascular Implant Surveillance & Interventional Outcomes Network [VISION]) database.

Methods

The VISION Database was queried for all patients undergoing CEA and TCAR between September 2016 to December 2019. The primary outcome was one-year and three-years survival. One-to-one propensity-score matching (PSM) without replacement was used to produce two well-matched cohorts. Kaplan-Meier estimates, and Cox regression were used for analyses. Exploratory analyses compared stroke rates using claims-based algorithms for comparison.

Results

A total of 43,714 patients underwent CEA and 8,089 patients underwent TCAR during the study period. Patients in the TCAR cohort were older and were more likely to have severe comorbidities. PSM produced two well-matched cohorts of 7,351 pairs of TCAR and CEA. In the matched cohorts, there were no differences in one-year death (HR=1.13, 95% CI: 0.99-1.30; P=0.065). At three-years, TCAR was associated with slight increased risk of death (HR=1.16, 95% CI: 1.04-1.30; P=0.008). When stratifying by initial symptomatic presentation, the increased three-year death associated with TCAR persisted only in symptomatic patients (HR=1.33, 95% CI: 1.08-1.63; P=0.008). Exploratory analyses of post-operative stroke rates using administrative sources suggested that validated measures of claims-based stroke ascertainment are necessary.

Conclusions

In this large multi-institutional PSM analysis with robust Medicare-linked follow-up for survival analysis, the rate of death at one-year was similar in TCAR and CEA regardless of symptomatic status. The slight increase in the risk of three-year death in symptomatic patients undergoing TCAR is likely confounded by more severe comorbidities despite matching. A randomized controlled trial comparing TCAR to CEA is necessary to further determine the role of TCAR in standard risk patients requiring carotid revascularization.