UC San Diego

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.