Transcarotid Artery Revascularization Sustains Its Advantage Over Transfemoral Carotid Artery Stenting in the Longer Term: Propensity Score-Matched Three-Year Outcomes

The superiority of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (TFCAS) has been established in the perioperative period with a lower risk of stroke and death. However, it remains unclear whether TCAR will sustain its advantage in the longer term. We evaluated the 3-year outcomes for death, transient ischemic attack (TIA), stroke, and myocardial infarction (MI) after TCAR and TFCAS. Data from the Vascular Quality Initiative carotid artery stenting database for patients who had undergone TCAR or TFCAS from 2017 to 2020 were analyzed. We used 1:1 propensity score matching to adjust for 36 baseline characteristics. The Student t test and χ2 test were used to compare the differences in patient characteristics and perioperative outcomes. Kaplan-Meier survival estimates and Cox hazard regression were used to evaluate the longer term outcomes. A total of 19,174 cases (TCAR, 7075; TFCAS, 12,099) were included. Before matching, the TCAR patients were older, had had higher rates of comorbid conditions, and had had higher risk medical and/or anatomic features compared with the TFCAS patients. The TFCAS patients were more likely to be symptomatic. Propensity matching yielded 5760 pairs with no major differences between the two groups. In the matched populations, during the perioperative period, TCAR was associated with a reduced incidence of in-hospital TIA (P = .015), stroke (P < .001), death (P < .001), reperfusion injury (P < .001), and postoperative complications (P < .001) compared with TFCAS. At 1 year after treatment, TCAR was associated with significant reductions in the rate of death (TCAR, 4.3%; vs TFCAS, 8.1%; P < .001) and the composite outcome of TIA/stroke/death/MI (TCAR, 5.9%; vs TFCAS, 9.6%; P < .001). TCAR sustained its advantage over TFCAS through year 3 (Fig 1). The cumulative 3-year risk of death was reduced by 48% (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.53-0.73; P < .001), and the risk of TIA/stroke/death/MI was reduced by 46% (HR, 0.64; 95% CI, 0.55-0.74; P < .001). However, no difference was found in the risk of TIA/stroke between TCAR and TFCAS in the longer term (HR, 1.08; 95% CI, 0.69-1.73; P = .72; Fig 2). The survival advantage of TCAR compared with TFCAS was sustained at 3 years. This advantage is likely established in the short term by the reduced rates of in-hospital stroke. However, no difference in the rates of mid- to long-term stroke were demonstrated between TCAR and TFCAS, suggesting that the intraoperative neuroprotection associated with TCAR is beneficial only in the perioperative period.Fig 2Kaplan-Meier survival estimate for matched populations for freedom from transient ischemic attack (TIA)/stroke. TCAR, Transcarotid artery revascularization; TFCAS, transfemoral carotid artery stenting.View Large Image Figure ViewerDownload Hi-res image Download (PPT)