Key PointsQuestion
What is the comparative risk of stroke after transcarotid
artery revascularization (TCAR) vs transfemoral carotid artery stenting
(TF-CAS) for patients with carotid artery stenosis?
Findings
In this comparative effectiveness study of 5798 asymptomatic
and 4721 symptomatic patients who underwent carotid stenting, TCAR was
associated with a lower risk of stroke than was TF-CAS. This finding was
consistent in both asymptomatic and symptomatic patients and was
durable over a 3-year interval.
Meaning
With no completed or enrolling randomized clinical trial to
evaluate TCAR, these comparative stroke risk results can inform future
procedure choice for patients who are considering carotid artery
stenting.
Importance
The effectiveness of surgical transcarotid artery
revascularization (TCAR) compared with percutaneous transfemoral carotid
artery stenting (TF-CAS) for stroke prevention beyond the
periprocedural period is poorly quantified.
Objective
To compare the risk of stroke after TCAR vs TF-CAS.
Design, Setting, and Participants
This retrospective cohort study used data from the Vascular
Implant Surveillance and Outcomes Network (VISION), a procedural
registry linked to Medicare claims data that captures clinical,
procedural, and outcome data on patients who underwent carotid stenting.
Patients who underwent TCAR or TF-CAS between October 1, 2016, and
December 31, 2019, and were captured in the VISION database were
included. Data were analyzed between January and June 2024.
Exposure
Type of carotid stenting (TCAR vs TF-CAS).
Main Outcomes and Measures
The primary outcomes were any stroke, including both
periprocedural and during follow-up, defined using a validated claims
code list, and death. Asymptomatic and symptomatic patients were
analyzed separately. Kaplan-Meier analysis was used to calculate the
cumulative incidence of the outcomes, and a multivariable Cox
proportional hazards model was used to determine hazard ratios (HRs).
Results
There were 5798 asymptomatic patients (mean [SD] age,
74.6 [7.7] years; 3631 male [62.6%]; 3482 underwent TCAR; 2316 underwent
TF-CAS) and 4721 symptomatic patients (mean [SD] age, 74.2 [8.3] years;
2969 male [62.9%]; 2377 underwent TCAR; 2344 underwent TF-CAS) who
underwent carotid stenting. Patients who underwent TCAR were older, more
likely to be female, and less likely to have had a prior ipsilateral
carotid revascularization procedure. Among asymptomatic patients, the
Kaplan-Meier 3-year risk of stroke was lower after TCAR (5.1%; 95% CI,
3.0%-7.1%) than TF-CAS (9.2%; 95% CI, 7.7%-10.7%) (log-rank P < .001).
The composite 3-year stroke or death risk after TCAR was 22.6% (95% CI,
18.8%-26.3%), compared with 31.4% (95% CI, 28.3%-34.3%) after TF-CAS
(log-rank P < .001). Compared with TCAR, the adjusted HR of
stroke after TF-CAS among asymptomatic patients was 1.69 (95% CI,
1.25-2.28; P < .001). Among patients with symptomatic carotid
stenosis, the 3-year stroke risk was also lower for TCAR (16.6%; 95% CI,
12.1%-20.9%) than for TF-CAS (20.9%; 95% CI, 17.5%-24.1%) (log-rank P < .001).
The composite 3-year stroke or death risk after TCAR was 35.9% (95% CI,
30.1%-41.2%), compared with 41.5% (95% CI, 37.6%-45.1%) after TF-CAS
(log-rank P < .001). Compared with TCAR, the adjusted HR for
stroke after TF-CAS among symptomatic patients was 1.42 (95% CI,
1.17-1.73; P < .001). Sensitivity analyses yielded similar results.
Conclusions and Relevance
In this comparative effectiveness study, TCAR was associated
with a lower risk of stroke than TF-CAS. This finding was consistent in
both asymptomatic and symptomatic patients and durable over a 3-year
interval. These findings can inform procedure choices for patients
considering carotid artery stenting.
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