Risk Stratified Outcomes of Carotid Endarterectomy vs Transcarotid Artery Revascularization

Transcarotid artery revascularization (TCAR) offers a minimally invasive alternative to carotid endarterectomy (CEA) in patients at high risk for CEA. Prior studies suggest nearly comparable stroke and mortality outcomes in asymptomatic patients, whereas CEA is associated with lower periprocedural stroke risk in symptomatic patients. Here, we compare TCAR and CEA in risk-stratified patients to assist with clinical decision-making. We performed a risk-stratified analysis of Vascular Quality Initiative patients who underwent CEA or TCAR (2017-2022). Patients were stratified as low-, medium-, and high-risk using the Vascular Study Group of New England's scoring system validated to predict post-CEA adverse outcomes. We conducted 1:1 propensity matching within risk categories to account for variations in baseline characteristics. We defined the primary end point as a composite of death, ipsilateral stroke, and myocardial infarction. We identified a total of 134,281 patients (CEA: 105,470/TCAR: 28,911). After 1:1 propensity matching, 8635 low-risk3,799 medium-risk and 3671 high-risk matched pairs were included for analysis. CEA and TCAR patients had no significant differences in the rates of 30-day primary end point or 30-day mortality across risk strata (Table). Among low-risk patients, the TCAR group had a higher incidence of postoperative ipsilateral stroke (1.0% vs 0.5%; P < .001) and higher risk adjusted odds of ipsilateral stroke (odds ratio [OR] 1.95 [95% confidence interval (CI), 1.36-2.78]; P < .001). In the medium-risk cohort, TCAR and CEA patients had comparable stroke rates (0.9% vs 1.0%; P = NS). Among high-risk patients, TCAR patients had higher post-op ipsilateral stroke (1.9% vs 1.1%; P < .01) and risk adjusted odds of ipsilateral stroke (OR, 1.70 [95% CI, 1.15-2.50]; P < .05). High-risk CEA patients also had a higher 1-year primary end point (8.50% vs 5.20%; P < .001) and risk-adjusted odds of 1-year primary end point (OR, 1.7 [95% CI, 1.41-2.04]; P < .001). The higher rate of 1-year primary end point was driven by a higher rate of 1-year mortality in the CEA group (7.5% vs 4.9%; P < .001); many patients were lost to 1-year follow-up for the stroke and myocardial infarction variables. In the 6-year survival analysis, CEA and TCAR patients had similar mortality hazards and long-term survival in all risk cohorts. In a risk-stratified analysis, patients undergoing CEA and patients undergoing TCAR had comparable postoperative and long-term mortality outcomes. While the rates of postoperative ipsilateral stroke remain low after both procedures, TCAR patients had significantly higher odds of postoperative ipsilateral stroke in the low- and high-risk cohorts.TablePropensity-matched outcomesLow-risk outcomesAll (n = 17,270)CEA (n = 8635)TCAR (n = 8635)P valueOddsP value30-Day primary end point238 (1.4)105 (1.2)133 (1.5)NS1.27 (0.98-1.65)NS30-Day mortality79 (0.5)37 (0.4)42 (0.5)NS1.13 (0.73-1.76)NSPostoperative ipsilateral stroke135 (0.8)46 (0.5)89 (1.0)<.0011.95 (1.36-2.78)<.001Myocardial infarction48 (0.3)29 (0.3)19 (0.2)NS0.66 (0.37-1.18)NS1-Year primary end point475 (2.80)251 (2.90)224 (2.60)NS0.89 (0.74-1.07)NSMedium-risk outcomesAll (n = 7598)CEA (n = 3799)TCAR (n = 3799)P valueOddsP value30-Day primary end point163 (2.1)87 (2.3)76 (2.0)NS1.87 (0.64-1.19)NS30-Day mortality71 (0.9)36 (0.9)35 (0.9)NS0.97 (0.61-1.55)NSPostoperative ipsilateral stroke72 (0.9)37 (1.0)35 (0.9)NS0.95 (0.59-1.50)NSMyocardial infarction36 (0.5)22 (0.6)14 (0.4)NS0.64 (0.32-1.24)NS1-Year primary end point389 (5.1)201 (5.3)188 (4.9)NS0.93 (0.76-1.14)NSHigh-risk outcomesAll (n = 7342)CEA (n = 3671)TCAR (n = 3671)P valueOddsP value30-Day primary end point237 (3.2)117 (3.2)120 (3.3)NS1.03 (0.79-1.33)NS30-Day mortality119 (1.6)69 (1.9)50 (1.4)NS0.72 (0.50-1.04)NSPostoperative ipsilateral stroke110 (1.5)41 (1.1)69 (1.9)<.011.70 1.15-2.50)<.05Myocardial infarction34 (0.5)22 (0.6)12 (0.3)NS0.54 (0.27-1.10)NS1-Year primary end point505 (6.9)313 (8.5)192 (5.2)<.0010.59 (0.49-0.71)<.001CEA, Carotid endarterectomy; NS, not significant; TCAR, transcarotid artery revascularization.Odds represent univariate logistic regression after 1:1 propensity score matching. Values are number (%) unless otherwise noted. Boldface P values represent statistical significance. Open table in a new tab