Risk of Stroke, Death, and Myocardial Infarction Following Transcarotid Artery Revascularization vs Carotid Endarterectomy in Patients With Standard Surgical Risk

Authors

Patric Liang, Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Jack L. Cronenwett, Section of Vascular Surgery, Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Eric A. Secemsky, Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Jens Eldrup-Jorgensen, Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland.Follow
Mahmoud B. Malas, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego Health System, San Diego.
Grace J. Wang, Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia.
Brian W. Nolan, Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland.Follow
Vikram S. Kashyap, Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, Michigan.
Raghu L. Motaganahalli, Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis.
Marc L. Schermerhorn, Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Document Type

Article

Publication Date

3-20-2023

Journal Title

JAMA Neurology

Abstract

IMPORTANCE: Carotid artery stenting has been limited to use in patients with high surgical risk; outcomes in patients with standard surgical risk are not well known. OBJECTIVE: To compare stroke, death, and myocardial infarction outcomes following transcarotid artery revascularization vs carotid endarterectomy in patients with standard surgical risk. DESIGN, SETTING, AND PARTICIPANTS: This retrospective propensity-matched cohort study was conducted from August 2016 to August 2019 with follow-up until August 31, 2020, using data from the multicenter Vascular Quality Initiative Carotid Artery Stent and Carotid Endarterectomy registries. Patients with standard surgical risk, defined as those lacking Medicare-defined high medical or surgical risk characteristics and undergoing transcarotid artery revascularization (n = 2962) or carotid endarterectomy (n = 35 063) for atherosclerotic carotid disease. In total, 760 patients were excluded for treatment of multiple lesions or in conjunction with other procedures. EXPOSURES: Transcarotid artery revascularization vs carotid endarterectomy. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite end point of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke. RESULTS: After 1:3 matching, 2962 patients undergoing transcarotid artery revascularization (mean [SD] age, 70.4 [6.9] years; 1910 [64.5%] male) and 8886 undergoing endarterectomy (mean [SD] age, 70.0 [6.5] years; 5777 [65.0%] male) were identified. There was no statistically significant difference in the risk of the primary composite end point between the 2 cohorts (transcarotid 3.0% vs endarterectomy 2.6%; absolute difference, 0.40% [95% CI, -0.43% to 1.24%]; relative risk [RR], 1.14 [95% CI, 0.87 to 1.50]; P = .34). Transcarotid artery revascularization was associated with a higher risk of 1-year ipsilateral stroke (1.6% vs 1.1%; absolute difference, 0.52% [95% CI, 0.03 to 1.08]; RR, 1.49 [95% CI, 1.05 to 2.11%]; P = .02) but no difference in 1-year all-cause mortality (2.6% vs 2.5%; absolute difference, -0.13% [95% CI, -0.18% to 0.33%]; RR, 1.04 [95% CI, 0.78 to 1.39]; P = .67). CONCLUSIONS AND RELEVANCE: In this study, the risk of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke was similar in patients undergoing transcarotid artery revascularization compared with those undergoing endarterectomy for carotid stenosis.

Recommended Citation

Liang P, Cronenwett JL, Secemsky EA, et al. Risk of Stroke, Death, and Myocardial Infarction Following Transcarotid Artery Revascularization vs Carotid Endarterectomy in Patients With Standard Surgical Risk [published online ahead of print, 2023 Mar 20]. JAMA Neurol. 2023;e230285. doi:10.1001/jamaneurol.2023.0285