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Association of Transcarotid Artery Revascularization vs Transfemoral Carotid Artery Stenting With Stroke or Death Among Patients With Carotid Artery Stenosis

Educational Objective
To learn about transcarotid artery revascularization with flow reversal.
1 Credit CME
Key Points

Question  Is transcarotid artery revascularization or transfemoral carotid artery stenting associated with a lower risk of stroke or death among patients undergoing treatment for carotid artery stenosis?

Findings  In this propensity score–matched analysis of data from 3286 matched pairs of patients who underwent transcarotid artery revascularization or transfemoral carotid artery stenting, the risk of in-hospital stroke or death was 1.6% with the transcarotid approach vs 3.1% with the transfemoral approach, a difference that was statistically significant.

Meaning  Among patients undergoing treatment for carotid stenosis, transcarotid artery revascularization, compared with transfemoral carotid artery stenting, was associated with a lower risk of stroke or death.

Abstract

Importance  Several trials have observed higher rates of perioperative stroke following transfemoral carotid artery stenting compared with carotid endarterectomy. Transcarotid artery revascularization with flow reversal was recently introduced for carotid stenting. This technique was developed to decrease stroke risk seen with the transfemoral approach; however, its outcomes, compared with transfemoral carotid artery stenting, are not well characterized.

Objective  To compare outcomes associated with transcarotid artery revascularization and transfemoral carotid artery stenting.

Design, Setting, and Participants  Exploratory propensity score–matched analysis of prospectively collected data from the Vascular Quality Initiative Transcarotid Artery Surveillance Project and Carotid Stent Registry of asymptomatic and symptomatic patients in the United States and Canada undergoing transcarotid artery revascularization and transfemoral carotid artery stenting for carotid artery stenosis, from September 2016 to April 2019. The final date for follow-up was May 29, 2019.

Exposures  Transcarotid artery revascularization vs transfemoral carotid artery stenting.

Main Outcomes and Measures  Outcomes included a composite end point of in-hospital stroke or death, stroke, death, myocardial infarction, as well as ipsilateral stroke or death at 1 year. In-hospital stroke was defined as ipsilateral or contralateral, cortical or vertebrobasilar, and ischemic or hemorrhagic stroke. Death was all-cause mortality.

Results  During the study period, 5251 patients underwent transcarotid artery revascularization and 6640 patients underwent transfemoral carotid artery stenting. After matching, 3286 pairs of patients who underwent transcarotid artery revascularization or transfemoral carotid artery stenting were identified (transcarotid approach: mean [SD] age, 71.7 [9.8] years; 35.7% women; transfemoral approach: mean [SD] age, 71.6 [9.3] years; 35.1% women). Transcarotid artery revascularization was associated with a lower risk of in-hospital stroke or death (1.6% vs 3.1%; absolute difference, −1.52% [95% CI, −2.29% to −0.75%]; relative risk [RR], 0.51 [95% CI, 0.37 to 0.72]; P < .001), stroke (1.3% vs 2.4%; absolute difference, −1.10% [95% CI, −1.79% to −0.41%]; RR, 0.54 [95% CI, 0.38 to 0.79]; P = .001), and death (0.4% vs 1.0%; absolute difference, −0.55% [95% CI, −0.98% to −0.11%]; RR, 0.44 [95% CI, 0.23 to 0.82]; P = .008). There was no statistically significant difference in the risk of perioperative myocardial infarction between the 2 cohorts (0.2% for transcarotid vs 0.3% for the transfemoral approach; absolute difference, −0.09% [95% CI, −0.37% to 0.19%]; RR, 0.70 [95% CI, 0.27 to 1.84]; P = .47). At 1 year using Kaplan-Meier life-table estimation, the transcarotid approach was associated with a lower risk of ipsilateral stroke or death (5.1% vs 9.6%; hazard ratio, 0.52 [95% CI, 0.41 to 0.66]; P < .001). Transcarotid artery revascularization was associated with higher risk of access site complication resulting in interventional treatment (1.3% vs 0.8%; absolute difference, 0.52% [95% CI, −0.01% to 1.04%]; RR, 1.63 [95% CI, 1.02 to 2.61]; P = .04), whereas transfemoral carotid artery stenting was associated with more radiation (median fluoroscopy time, 5 minutes [interquartile range {IQR}, 3 to 7] vs 16 minutes [IQR, 11 to 23]; P < .001) and more contrast (median contrast used, 30 mL [IQR, 20 to 45] vs 80 mL [IQR, 55 to 122]; P < .001).

Conclusions and Relevance  Among patients undergoing treatment for carotid stenosis, transcarotid artery revascularization, compared with transfemoral carotid artery stenting, was significantly associated with a lower risk of stroke or death.

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Article Information

Corresponding Author: Marc L. Schermerhorn, MD, Beth Israel Deaconess Medical Center, 110 Francis St, Ste 5B, Boston, MA 02215 (mscherm@bidmc.harvard.edu).

Accepted for Publication: October 19, 2019.

Author Contributions: Drs Schermerhorn and Liang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Schermerhorn and Liang contributed equally to this article.

Concept and design: Schermerhorn, Liang, Eldrup-Jorgensen, Cronenwett, Motaganahalli, Malas.

Acquisition, analysis, or interpretation of data: Schermerhorn, Liang, Nolan, Kashyap, Wang.

Drafting of the manuscript: Schermerhorn, Liang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Schermerhorn, Liang, Kashyap.

Administrative, technical, or material support: Schermerhorn, Cronenwett.

Supervision: Schermerhorn, Eldrup-Jorgensen, Wang, Malas.

Conflict of Interest Disclosures: Dr Schermerhorn reported receipt of personal fees for provision of consultancy services from Silk Road Medical, Abbott, Cook, Endologix and Medtronic outside the submitted work. Dr Kashyap reported being a national coprimary investigator for the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTERII). Dr Motaganahalli reported other for provision of consultancy services from Silk Road Medical during the conduct of the study. Dr Malas reported being a site principal investigator for the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) and the ROADSTERI and ROADSTERII trials, a national primary investigator for the ROADSTERI long-term follow-up study, and being a proctor for TCAR. No other disclosures were reported.

Funding/Support: Dr Liang is supported by the Harvard-Longwood Research Training in Vascular Surgery National Institutes of Health (NIH) T32 grant (5T32HL007734-22). This work was conducted with support from Harvard Catalyst—The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH award (UL1 TR001102), and financial contributions from Harvard University and its affiliated academic health care centers.

Role of the Funder/Sponsor: The Society for Vascular Surgery Patient Safety Organization was not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or NIH.

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