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.

Background and purpose

Advancements in carotid revascularization have produced promising outcomes in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization procedures after symptomatic presentation remains unclear. The purpose of this study is to compare in-hospital outcomes of transcarotid artery revascularization (TCAR), transfemoral carotid stenting (TFCAS), or carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms.

Methods

This is a retrospective cohort study of United States patients in the vascular quality initiative. All carotid revascularizations performed for symptomatic carotid artery stenosis between September 2016 and November 2019 were included. Procedures were categorized as urgent (0-2 days after most recent symptom), early (3-14 days), or late (15-180 days). The primary outcome of interest was in-hospital stroke and death. Secondary outcomes include in-hospital stroke, death, and transient ischemic attacks. Multivariable logistic regression was used to compare outcomes.

Results

A total of 18 643 revascularizations were included: 2006 (10.8%) urgent, 7423 (39.8%) early, and 9214 (49.42%) late. Patients with TFCAS had the highest rates of stroke/death at all timing cohorts (urgent: 4.0% CEA, 6.9% TFCAS, 6.5% TCAR, P=0.018; early: 2.5% CEA, 3.8% TFCAS, 2.9% TCAR, P=0.054; late: 1.6% CEA, 2.8% TFCAS, 2.3% TCAR, P=0.003). TFCAS also had increased odds of in-hospital stroke/death compared with CEA in all 3 groups (urgent adjusted odds ratio [aOR], 1.7 [95% CI, 1.0-2.9] P=0.03; early aOR, 1.6 [95% CI, 1.1-2.4] P=0.01; and late aOR, 1.9 [95% CI, 1.2-3.0] P=0.01). TCAR and CEA had comparable odds of in-hospital stroke/death in all 3 groups (urgent aOR, 1.9 [95% CI, 0.9-4], P=0.10), (early aOR, 1.1 [95% CI, 0.7-1.7], P=0.66), (late aOR, 1.5 [95% CI, 0.9-2.3], P=0.08).

Conclusions

CEA remains the safest method of revascularization within the urgent period. Among revascularization performed outside of the 48 hours, TCAR and CEA have comparable outcomes.