Transcarotid artery revascularization outperforms transfemoral carotid artery stenting regardless of aortic arch type or degree of atherosclerosis.

Abstract

Objective: The Centers for Medicare and Medicaid Services now approve reimbursement for transfemoral carotid artery stenting (TFCAS) in the treatment of standard-risk patients with carotid artery occlusive disease. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes. Transcarotid artery revascularization (TCAR) could be a preferable alternative in these patients owing to avoiding the aortic arch and using flow reversal during stent deployment. We aim to compare the outcomes of TCAR vs TFCAS across all aortic arch types and degrees of arch atherosclerosis.

Methods: All patients undergoing carotid artery stenting between September 2016 and October 2023 were identified in the Vascular Quality Initiative database. Patients were stratified into four groups: Group A (mild atherosclerosis and type I/II arch), Group B (mild atherosclerosis and type III arch), Group C (moderate/severe atherosclerosis and type I/II arch), and Group D (moderate/severe atherosclerosis and type III arch). The primary outcome was in-hospital composite stroke or death. Analysis of variance and χ² tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. Kaplan-Meier survival estimates, log rank test, and multivariable Cox regression models analyzed hazard ratios for 1-year mortality.

Results: A total of 20,114 patients were included (Group A: 12,980 [64.53%]; Group B: 1175 [5.84%]; Group C: 5124 [25.47%]; and Group D: 835 [4.15%]). TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94%, and 69.22%; P < .001). Compared with patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group C and Group D were more likely to be female, hypertensive, smokers, and have chronic kidney disease. Patients with type III arch in Group B and Group D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than one-half the risk of stroke/death and 1-year mortality compared with TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (Group A) (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .001; hazard ratio, 0.42; 95% CI, 0.32-0.57; P < .001). Group B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared with TFCAS (OR, 0.30; 95% CI, 0.12-0.75; P = .01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR, 0.66; 95% CI, 0.44-0.97; P = .037). There was no significant difference in odds of stroke/death in patients with advanced arch atherosclerosis and complex arch (Group D) (OR, 0.91; 95% CI, 0.39-2.16; P = .834).

Conclusions: TCAR is safer than TFCAS in patients with simple and advanced arch anatomy. This could be related to the efficiency of flow reversal vs distal embolic protection. The current Centers for Medicare and Medicaid Services decision will likely increase stroke and death outcomes of carotid stenting nationally if multidisciplinary approach and appropriate patient selection are not implemented.