Seven Years of The Transcarotid Artery Revascularization Surveillance Project, Comparison To Transfemoral Stenting And Endarterectomy

Sabrina Straus, Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego (UCSD), San Diego, California.
Sai Divya Yadavalli, Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Sara Allievi, Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
Andrew Sanders, Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Roger B. Davis, Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Mahmoud B. Malas, Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego (UCSD), San Diego, California.
Grace J. Wang, Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
Vikram S. Kashyap, Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI.
Jack Cronenwett, Section of Vascular Surgery, Dartmouth Medical School, 1 Medical Center Drive, Lebanon, NH.
Raghu L. Motaganahalli, Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
Brian Nolan, Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME.
Jens Eldrup-Jorgensen, Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME.
Marc Schermerhorn, Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. Electronic address: mscherm@bidmc.harvard.edu.

Abstract

OBJECTIVE: This study utilizes the latest data from the Vascular Quality Initiative (VQI), which now encompasses over 50,000 transcarotid artery revascularization (TCAR) procedures, to offer a sizeable dataset for comparing the effectiveness and safety of TCAR, transfemoral carotid artery stenting (tfCAS), and carotid endarterectomy (CEA). Given this substantial dataset, we are now able to compare outcomes overall and stratified by symptom status across revascularization techniques. METHODS: Utilizing VQI data from September 2016 to August 2023, we conducted a risk-adjusted analysis by applying inverse probability of treatment weighting to compare in-hospital outcomes between TCAR vs tfCAS, CEA vs tfCAS, and TCAR vs CEA. Our primary outcome measure was in-hospital stroke/death. Secondary outcomes included myocardial infarction and cranial nerve injury. RESULTS: A total of 50,068 patients underwent TCAR, 25,361 patients underwent tfCAS, and 122,737 patients underwent CEA. TCAR patients were older, more likely to have coronary artery disease, chronic kidney disease, and undergo coronary artery bypass grafting/percutaneous coronary intervention as well as prior contralateral CEA/CAS compared to both CEA and tfCAS. TfCAS had higher odds of stroke/death when compared with TCAR (2.9% vs 1.6%, aOR=1.84, 95% CI:1.65-2.06; P<.001) and CEA (2.9% vs 1.3%, aOR=2.21, 95% CI:2.01-2.43; P<.001). CEA had slightly lower odds of stroke/death compared with TCAR (1.3% vs 1.6%, aOR=0.83, 95% CI:0.76-0.91; P<.001). TfCAS had lower odds of cranial nerve injury compared with TCAR (0.0% vs 0.3%, aOR=0.00, 95% CI:0.00-0.00; P<.001) and CEA (0.0% vs 2.3%, aOR=0.00, 95% CI:0.0-0.0; P<.001) as well as lower odds of myocardial infarction compared with CEA (0.4% vs 0.6%, aOR=0.67, 95% CI:0.54-0.84; P<.001). CEA compared with TCAR had higher odds of myocardial infarction (0.6% vs 0.5%, aOR=1.31, 95% CI:1.13-1.54; P<.001) and cranial nerve injury (2.3% vs 0.3%, aOR=9.42, 95% CI:7.78-11.4; P<.001). CONCLUSIONS: While tfCAS may be beneficial for select patients, the lower stroke/death rates associated with CEA and TCAR are preferred. When deciding between CEA and TCAR, it's important to weigh additional procedural factors and outcomes such as myocardial infarction and cranial nerve injury, particularly when stroke/death rates are similar. Additionally, evaluating subgroups that may benefit from one procedure over another is essential for informed decision-making and enhanced patient care in the treatment of carotid stenosis.