Effectiveness of Transcarotid vs Transfemoral Carotid Stenting for Stroke Prevention

Importance The effectiveness of surgical transcarotid artery revascularization (TCAR) compared with percutaneous transfemoral carotid artery stenting (TF-CAS) for stroke prevention beyond the periprocedural period is poorly quantified. Objective To compare the risk of stroke after TCAR vs TF-CAS. Design, Setting, and Participants This retrospective cohort study used data from the Vascular Implant Surveillance and Outcomes Network (VISION), a procedural registry linked to Medicare claims data that captures clinical, procedural, and outcome data on patients who underwent carotid stenting. Patients who underwent TCAR or TF-CAS between October 1, 2016, and December 31, 2019, and were captured in the VISION database were included. Data were analyzed between January and June 2024. Exposure Type of carotid stenting (TCAR vs TF-CAS). Main Outcomes and Measures The primary outcomes were any stroke, including both periprocedural and during follow-up, defined using a validated claims code list, and death. Asymptomatic and symptomatic patients were analyzed separately. Kaplan-Meier analysis was used to calculate the cumulative incidence of the outcomes, and a multivariable Cox proportional hazards model was used to determine hazard ratios (HRs). Results There were 5798 asymptomatic patients (mean [SD] age, 74.6 [7.7] years; 3631 male [62.6%]; 3482 underwent TCAR; 2316 underwent TF-CAS) and 4721 symptomatic patients (mean [SD] age, 74.2 [8.3] years; 2969 male [62.9%]; 2377 underwent TCAR; 2344 underwent TF-CAS) who underwent carotid stenting. Patients who underwent TCAR were older, more likely to be female, and less likely to have had a prior ipsilateral carotid revascularization procedure. Among asymptomatic patients, the Kaplan-Meier 3-year risk of stroke was lower after TCAR (5.1%; 95% CI, 3.0%-7.1%) than TF-CAS (9.2%; 95% CI, 7.7%-10.7%) (log-rank P < .001). The composite 3-year stroke or death risk after TCAR was 22.6% (95% CI, 18.8%-26.3%), compared with 31.4% (95% CI, 28.3%-34.3%) after TF-CAS (log-rank P < .001). Compared with TCAR, the adjusted HR of stroke after TF-CAS among asymptomatic patients was 1.69 (95% CI, 1.25-2.28; P < .001). Among patients with symptomatic carotid stenosis, the 3-year stroke risk was also lower for TCAR (16.6%; 95% CI, 12.1%-20.9%) than for TF-CAS (20.9%; 95% CI, 17.5%-24.1%) (log-rank P < .001). The composite 3-year stroke or death risk after TCAR was 35.9% (95% CI, 30.1%-41.2%), compared with 41.5% (95% CI, 37.6%-45.1%) after TF-CAS (log-rank P < .001). Compared with TCAR, the adjusted HR for stroke after TF-CAS among symptomatic patients was 1.42 (95% CI, 1.17-1.73; P < .001). Sensitivity analyses yielded similar results. Conclusions and Relevance In this comparative effectiveness study, TCAR was associated with a lower risk of stroke than TF-CAS. This finding was consistent in both asymptomatic and symptomatic patients and durable over a 3-year interval. These findings can inform procedure choices for patients considering carotid artery stenting.