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Original Investigation
December 17, 2019

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

Author Affiliations
  • 1Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
  • 2Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland
  • 3Section of Vascular Surgery and The Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
  • 4Division of Vascular and Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
  • 5Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
  • 6Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis
  • 7Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego
JAMA. 2019;322(23):2313-2322. doi:10.1001/jama.2019.18441
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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