Comparison of Transcarotid Artery Revascularization And Transfemoral Carotid Artery Stenting Outcomes Among Symptomatic And Asymptomatic Patients Based On Lesion Calcification

Abstract

INTRODUCTION AND OBJECTIVES Anatomic details affecting adverse outcomes following transcarotid artery stenting are not well characterized. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients stratified by degree of lesion calcification. METHODS Data from patients in the Society for Vascular Surgery Vascular Quality Initiative database undergoing TCAR (Jan 2017 to Apr 2020) or TFCAS (May 2005 to Apr 2020) and had carotid artery calcification grading was analyzed. Degree of calcification was stratified into three groups: none, <=50% calcification, and >50% calcification. RESULTS A total of 9,868 patients (TCAR:4,224; TFCAS:5,644) were included. TCAR patients were generally older, white, smokers, and had more comorbidities than TFCAS patients. Among symptomatic patients, there was no difference in rates of stroke, stroke/TIA, and MI by calcification severity between TCAR and TFCAS. However, there was a trend towards increased risk in all three events with higher calcification only after TFCAS. Symptomatic patients with severe (>50%) calcification had lower rates of death (TCAR:0.9% vs TFCAS:2.8%, P=0.013), stroke/death (TCAR:2.7% vs TFCAS:5.8%, P=0.006), stroke/death/MI (TCAR:3.3% vs TFCAS:6.5%, P=0.007), and postop complications (TCAR:6.0% vs TFCAS:12.4%, P<0.001) compared to TFCAS. Furthermore, TCAR had lower risk of death at all degrees of calcification compared to TFCAS. Similar findings were noted among asymptomatic TCAR patients with >50% calcification, in which the rates of death (TCAR:0.4% vs TFCAS:1.1%, P=0.080) and stroke/death (TCAR:1.5% vs TFCAS:3.1%, P=0.029) were reduced. CONCLUSIONS While increased calcification increased rates of adverse events after TFCAS, this trend was not observed after TCAR. Furthermore, TCAR had lower rates of death than TFCAS across all degrees of calcification and lower rates of stroke/death among patients with severe calcification. These findings suggesting that TCAR is protective against death despite anatomic differences and may be particularly beneficial over TFCAS in patients with calcified lesions. Anatomic details affecting adverse outcomes following transcarotid artery stenting are not well characterized. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients stratified by degree of lesion calcification. Data from patients in the Society for Vascular Surgery Vascular Quality Initiative database undergoing TCAR (Jan 2017 to Apr 2020) or TFCAS (May 2005 to Apr 2020) and had carotid artery calcification grading was analyzed. Degree of calcification was stratified into three groups: none, <=50% calcification, and >50% calcification. A total of 9,868 patients (TCAR:4,224; TFCAS:5,644) were included. TCAR patients were generally older, white, smokers, and had more comorbidities than TFCAS patients. Among symptomatic patients, there was no difference in rates of stroke, stroke/TIA, and MI by calcification severity between TCAR and TFCAS. However, there was a trend towards increased risk in all three events with higher calcification only after TFCAS. Symptomatic patients with severe (>50%) calcification had lower rates of death (TCAR:0.9% vs TFCAS:2.8%, P=0.013), stroke/death (TCAR:2.7% vs TFCAS:5.8%, P=0.006), stroke/death/MI (TCAR:3.3% vs TFCAS:6.5%, P=0.007), and postop complications (TCAR:6.0% vs TFCAS:12.4%, P<0.001) compared to TFCAS. Furthermore, TCAR had lower risk of death at all degrees of calcification compared to TFCAS. Similar findings were noted among asymptomatic TCAR patients with >50% calcification, in which the rates of death (TCAR:0.4% vs TFCAS:1.1%, P=0.080) and stroke/death (TCAR:1.5% vs TFCAS:3.1%, P=0.029) were reduced. While increased calcification increased rates of adverse events after TFCAS, this trend was not observed after TCAR. Furthermore, TCAR had lower rates of death than TFCAS across all degrees of calcification and lower rates of stroke/death among patients with severe calcification. These findings suggesting that TCAR is protective against death despite anatomic differences and may be particularly beneficial over TFCAS in patients with calcified lesions.