Transcarotid artery revascularization associated with lower risk of stroke or death

1. In patients receiving carotid stenosis treatment, transcarotid artery revascularization was associated with a significantly lower risk of stroke or death compared to transfemoral carotid artery stenting.

Evidence Rating Level:2 (Good)

Study Rundown: Transfemoral carotid artery stenting has served as an alternative approach to the standard of care, for patients requiring treatment for carotid artery stenosis.  However, the transfemoral approach has been linked with a higher periprocedural stroke risk when compared to the transcarotid approach.  This study examined the risk of stroke or death in patients undergoing treatment for carotid artery stenosis via the transcarotid approach versus the transfemoral approach.  The exploratory propensity score-matched analysis revealed that transfemoral carotid artery stenting was associated with significantly higher risk of stroke or death compared to the transcarotid artery stenting.

The study was limited by its observational design, leading to a lack of randomization which may have led to confounding by indication.  The analysis was conducted over selected clinical registries; thus, the population characteristics are limited to the participating sites.  Furthermore, neurological testing or imaging was not a formalized criterion for the study procedure.

Click to read the study in JAMA

Relevant Reading: Randomized trial of stent versus surgery for asymptomatic carotid stenosis.

In-Depth [prospective cohort]: This study analyzed data from a CMS-approved prospective study, namely Initiative Transcarotid Artery Revascularization Surveillance Project and the Transfemoral Carotid Artery Stent Registry.  This registry combines data from participating centers located in the United States and Canada.  Asymptomatic and symptomatic patients with carotid artery stenosis undergoing transcarotid artery revascularization or transfemoral carotid artery stenting were identified from September 2016 to April 2019, and the study was concluded in May 2019.  Patients were excluded if they had traumatic, dissection, and uncharacterized carotid lesions present or were receiving carotid stenting in conjunction with planned intracranial interventions or those with unknown symptom status or severity (ie; transient ischemic attack or stroke).  A total of 11891 cases were analyzed, where 5251 underwent transcarotid artery revascularization and 6640 underwent transfemoral carotid artery stenting.  There was a lower risk of in-hospital stroke or death with transcarotid artery revascularization (1.6% vs 3.1% with absolute difference of −1.52%[95%CI, −2.29% to −0.75%]), and a lower risk of perioperative myocardial infarction, although this procedure was linked with higher risk of access site complication resulting in a follow up treatment (1.3% vs 0.8% with an absolute difference of 0.52%[95%CI, −0.01% to 1.04%]).

Image: PD

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