Favorable Outcomes After Transcarotid Stenting With Reverse Flow Neuroprotection and Carotid Endarterectomy in High-Risk Patients in a High-Volume Multisurgeon Practice

Transcarotid artery revascularization (TCAR) with reverse flow neuroprotection is emerging as an alternative to transfemoral carotid stenting and carotid endarterectomy (CEA). Previous studies suggest favorable outcomes and safety profiles. However, few studies have directly compared transcarotid revascularization outcomes with open modalities in high-risk patients. The purpose of the study was to compare outcomes after TCAR and CEA within a large vascular surgery practice after 1 year. A retrospective univariate comparative analysis was performed of 269 patients undergoing carotid revascularization with high-risk criteria as defined by national coverage criteria for carotid stenting. CEA and TCAR were compared with statistical significance set at P < .05 a priori. The primary outcome evaluated was postoperative stroke or transient ischemic attack, with secondary outcomes of perioperative myocardial infarction, cranial nerve injury, operative time, and reintervention at 1 year. Eighty-four TCARs and 184 high-risk CEAs performed between 2014 and 2018 were matched for analysis. Baseline characteristics were similar with regard to age (70.6 vs 71.1 years; P = .641), sex (56% vs 63% male; P = .234), preprocedural stroke rates (41.4% vs 41.6%; P = .982), body mass index (28.2 vs 29.3; P = .116), and current smoking rates (20.7% vs 23.6%; P = .489). Postoperative complications at 1 year were not different between the cohorts. No statistical differences were observed in stroke or transient ischemic attack (3.6% vs 1.1%; P = .151), myocardial infarction (0.9% vs 1.1%; P = .856), and re-exploration (1.8% vs 1.1%; P = .676) at 1 year. There were three cranial nerve injuries in the CEA cohort and none in the TCAR cohort (P = .856). The procedure time was significantly shorter for the TCAR group (62 vs 100 minutes; P < .001). Postoperative complication rates were similar between high-risk patients undergoing TCAR and CEA in a contemporary vascular surgery practice. This study adds to a growing body of literature supporting the use of TCAR in patients who are high risk for CEA. This study supports a prospective trial design to understand which patients are best served by endovascular compared with traditional open revascularization in stroke prevention.TableTCARCEAPAge Mean70.671.1.641 St Dev10.78.7 IQR65.5-77.065.2-77.2Prior Stroke/TIA No58.6% (65)58.4% (104).982 Yes41.4% (46)41.6% (74)BMI Mean28.229.3.116 St Dev5.35.9 IQR23.9-31.625.6-32.5Sex Female44.1% (49)37.1% (66).234 Male55.9% (62)62.9% (112)Smoking Current20.7% (23)23.6% (42).489 Former60.4% (67)48.9% (87) Never18.9% (21)27.5% (49)Race African American4.5% (5)5.1% (9).119 Asian2.7% (3)1.1% (2) Caucasian89.2% (99)84.7% (150) Unknown3.6% (4)9.0% (16)Stroke No96.4% (107)98.9% (176).151 Yes3.6% (4)1.1% (2)MI No99.1% (110)98.9% (176).856 Yes0.9% (1)1.1% (2)Cranial Nerve Inj No100.0% (111)98.9% (176).856 Yes0.0% (0)1.1% (2)Re-intervention No98.2% (109)98.9% (184).676 Yes1.8% (2)1.1% (2)Mortality No92.8% (103)96.1% (171).183 Yes7.2% (8)3.9% (7)Procedure Time (minutes) Mean62100