Propensity Score-Matched Analysis of 1-Year Outcomes of Transcarotid Revascularization With Dynamic Flow Reversal, Carotid Endarterectomy, and Transfemoral Carotid Artery Stenting

ABSTRACT Objectives Initial studies showed no significant differences in perioperative stroke or death between transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA) and lower stroke/death rates after TCAR compared with transfemoral carotid artery stenting (TFCAS). This study focuses on the one-year outcomes of ipsilateral stroke or death after TCAR, CEA, and TFCAS. Methods All patients undergoing TCAR, TFCAS and CEA between September 2016 to December 2019 were identified in the Vascular Quality Initiative (VQI) database. The latest follow up was September 3, 2020. One-to-one propensity-score-matched analysis was performed for patients with available one-year follow-up data for TCAR vs. CEA and for TCAR vs. TFCAS. Kaplan-Meier survival and Cox proportional hazard regression analyses were used to evaluate 1-year ipsilateral stroke or death after the three procedures. Results A total of 41,548 patients underwent CEA, 5,725 patients underwent TCAR, and 6,064 patients underwent TFCAS during the study period and had recorded one-year outcomes. The cohorts were well-matched in terms of baseline demographics and comorbidities. Among 4,180 TCAR vs. CEA matched pairs of patients, there were no significant differences in 30-day stroke, death, and stroke/death. However, TCAR was associated with a lower risk of 30-day stroke/death/MI (2.30% vs. 3.25%; RR (95%CI): 0.71 (0.55-0.91), P=.008), driven by a lower risk of MI (0.55% vs. 1.12%; HR (95%CI): 0.49 (0.30-0.81), P=.004). At one-year, no significant difference was observed in the risk of ipsilateral stroke or death (6.49% vs. 5.68%; HR (95% CI): 1.14 (0.95-1.37), P=.157). Among 4,036 matched pairs in the TCAR vs. TFCAS group, TCAR was also associated with lower risk of perioperative stroke or death compared to TFCAS (1.83% vs. 2.55%; HR (95% CI): 0.72 (0.54-0.96), P=.027). At one year, the risks of ipsilateral stroke or death of TCAR and TFCAS were comparable (6.07% vs. 7.07%; HR (95% CI): 0.85 (0.71-1.01), P=.07). Symptomatic status did not modify the association in TCAR vs. CEA. However, asymptomatic patients had favorable outcomes with TCAR vs TFCAS at 1-year [HR (95%CI): 0.78 (0.62-0.98), P=.033]. Conclusion In this propensity-score matched analysis, no significant differences in ipsilateral stroke/death free survival were observed between TCAR and CEA or between TCAR and TFCAS. The advantages of TCAR compared to TFCAS seem to be mainly in the peri-operative period, which makes it a suitable minimally invasive option for surgically high-risk patients with carotid artery stenosis. Larger studies, with longer follow-up and data on restenosis; are warranted to confirm the mid- and long-term benefits and durability of TCAR.