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Transcarotid Artery Revascularization vs. Transfemoral Carotid Artery Stenting for Carotid Artery Stenosis Treatment

This study compares the outcomes of transcarotid artery revascularization (TCAR) with flow reversal to transfemoral carotid artery stenting (tfCAS) for the treatment of carotid artery stenosis. Preliminary analysis shows lower neurological complications with TCAR. The study examines perioperative and one-year outcomes of patients undergoing TCAR and tfCAS.

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Transcarotid Artery Revascularization vs. Transfemoral Carotid Artery Stenting for Carotid Artery Stenosis Treatment

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  1. Transcarotid Artery Revascularization versus Transfemoral Carotid Artery Stenting for Treatment of Carotid Artery Stenosis Patric Liang, MD; Marc L. Schermerhorn, MD; Jens Eldrup-Jorgensen, MD; Jack L. Cronenwett, MD; Brian W. Nolan, MD; Vikram S. Kashyap, MD; Grace J. Wang, MD, MSCE; MD; Raghu L. Motaganahalli, MD; Mahmoud B. Malas, MD, MHS

  2. Disclosures • MS is a consultant for Silk Road Medical, Medtronic, Endologix, Cook, and Abbott • VK is a National Co-PI for ROADSTERII. • RM is a consultant and proctor for Silk Road Medical. • MM is a site PI for ROADSTERI and ROADSTERII, and National PI for ROADSTERI long term follow-up study. • PL, JJ, JC, BN, and GW have no disclosures.

  3. Pivotal randomized trails have found higher periprocedural stroke risk for transfemoral carotid stenting (tfCAS) compared to endarterectomy • Transcarotid revascularization (TCAR) with flow reversal was developed to eliminate the high embolic-risk maneuvers inherent to tfCAS • Preliminary analysis from the VQI TCAR Surveillance Project showed lower neurological complications based on embolic events manifested as transient ischemic attack • Limited to small sample size

  4. TCAR and tfCAS Trend in the VQI

  5. Examine perioperative and one-year outcomes of patients undergoing TCAR and tfCAS in the VQI TCAR Surveillance Project.

  6. Prospective registry, clinical trial (NCT02850588) • Study Period: September 2016 to April 2019 • Inclusion - • TCAR and tfCAS procedures for atherosclerotic or intimal hyperplasic disease • Exclusion – • Concomitant planned intracranial procedures • Unknown presenting symptom status or presenting symptom severity • Primary Outcome • In-hospital, 30-day, and 1-year stroke/death • Secondary Outcomes • Stroke, death, myocardial infarction, bleeding complication, procedure time, fluoroscopy time, contrast volume, CMS discharge criteria (failed discharge home or LOS >2 days) • Propensity Score Matched Analysis

  7. Baseline Characteristics

  8. Baseline Characteristics

  9. Propensity Score Matching 3286 Matched Pairs

  10. Technical Outcomes

  11. In-Hospital Outcomes

  12. In-Hospital Outcomes

  13. Protamine Use in TCAR

  14. 30-day Outcomes

  15. TCAR Freedom From Stroke/Death: 1-Year tfCAS 94.9% vs 90.5% HR 0.55, 95%CI 0.46-0.66, P < .001 Number at Risk Transfemoral Transcarotid

  16. TCAR is associated with lower rates of stroke and death compared to tfCAS • The stroke/death differences persistent up to one-year • Benefits from TCAR are particularly compelling for symptomatic carotid disease • Protamine use in TCAR results in significantly decreased bleeding complications without differences in thrombotic complications • TCAR with flow reversal should be preferred carotid stenting technique

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