Outcomes of carotid artery stenting for nonatherosclerotic disease.

Abstract

Objective: This study aims to evaluate and compare the outcomes of transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (tfCAS) in patients with nonatherosclerotic carotid diseases, including dissection, trauma, and fibromuscular dysplasia.

Methods: Patients who underwent TCAR and tfCAS for nonatherosclerotic carotid diseases between 2016 and 2024 were identified in the Vascular Quality Initiative (VQI) database. Patients were classified into TCAR or tfCAS based on the procedure performed. Baseline characteristics, demographics, and operative details were collected. Primary outcomes included stroke, death, and major adverse cardiovascular events (MACE), which was defined as the composite of stroke, myocardial infarction, and death. Secondary outcomes included perioperative complications. Descriptive statistics, univariable comparisons, and multivariable logistic regression analyses were performed to evaluate the association between procedure type and outcomes. A two-tailed P value of <.05 was considered statistically significant.

Results: Six hundred seventy six patients were identified (tfCAS, n = 503; TCAR, n = 173). TCAR patients were older (64 ± 14 years vs 56 ± 16 years; P < .001), and had higher rates of hypertension (74% vs 60.4%; P = .001) and coronary artery disease (34.1% vs 22.2%; P = .002). Dissection was the most common etiology (TCAR, 77.5%; tfCAS, 77.9%), followed by fibromuscular dysplasia (TCAR, 14.5%; tfCAS, 10.5%) then trauma (TCAR, 8.1%; tfCAS, 11.5%). Intraoperatively, TCAR patients had shorter fluoroscopy times (5 minutes vs 18.25 minutes; P < .001) and required less radiocontrast (30 mL vs 95 mL; P < .001), but had slightly longer procedure times (75.5 minutes vs 69 minutes; P = .055). When analyzed by procedure type, TCAR was associated with significantly lower rates of MACE (1.2% vs 7%; P = .004) and stroke/death (1.2% vs 6.4%; P = .007) compared with tfCAS. Furthermore, when stratified by symptomatic status, TCAR consistently had lower rates of MACE and stroke/death. On multivariate analysis, TCAR was independently associated with a significantly lower risk of MACE (odds ratio, 0.09; 95% confidence interval, 0.01-0.74; P = .025) and stroke/death (odds ratio, 0.11; 95% confidence interval, 0.01-0.95; P = .045).

Conclusions: TCAR was associated with superior perioperative outcomes compared with tfCAS in the treatment of nonatherosclerotic carotid diseases. These findings highlight TCAR's potential to be a safer and more effective treatment option for this challenging patient population.