Institutional Experiences with Transfemoral Compared to Transcarotid Stenting

Abstract

Transcarotid artery revascularization (TCAR) is a new surgical technique that is gaining popularity over the transfemoral method (TF-CAS) as the preferred strategy to deliver a carotid stent. This investigation was performed to evaluate the real-world perioperative and long-term outcomes of both techniques at the health system level. A retrospective review of prospectively maintained carotid revascularization databases were performed at 2 high-volume TCAR centers in the United States to extract consecutive TF-CAS and TCAR procedures. The characteristics and outcomes associated with these 2 modalities were compared at the preoperative and perioperative points by univariate methods. The Kaplan-Meier methodology was utilized to calculate the long-term stroke and death trends. From 2008-2021, 1,058 carotid stents were implanted at our institutions, consisting of 750 TCARs and 308 TF-CAS procedures. Patients undergoing TF-CAS were older (68.2±0.6 vs. 73.1±0.3years, P<0.01) and unhealthier by Charlson Comorbidity Index (4.9±0.1 vs. 5.5±0.1, P<0.01). Additionally, TF-CAS patients had more high-risk anatomic characteristics, such as restenosis after previous carotid surgery (27.0% vs. 9.5%, P<0.01), previous ipsilateral neck surgery (38.8% vs. 11.5%, P<0.01), irradiated ipsilateral field (20.4% vs. 4.5%, P<0.01), and a contralateral carotid occlusion (10.4% vs. 4.6%, P<0.01). The incidence of symptomatic lesions was the same (40.1% vs. 36.9%, P=0.35). Within the operating room, TCAR outperformed TF-CAS with respect to operative time (83.2±2.6 vs. 64.3±0.9min, P<0.01), radiation exposure (769.9±144.3 vs. 232.7±19.1mGys, P<0.01), fluoroscopic time (17.8±1.1 vs. 4.5±0.1min, P<0.01), and contrast volume (75.2±2.4 vs. 22.6±0.4mLs, P<0.01). In the 30-day perioperative period, ipsilateral stroke (2.8% vs. 2.3%, P=0.65), contralateral stroke (1.0% vs. 0.1%, P=0.07), and death (1.0% vs. 1.2%, P>0.99) were similar between modalities. None of these endpoints, including a composite of stroke and death (4.8% vs. 3.6%, P=0.38), reached statistical significance. Additionally, we found no differences with respect to stroke-free survival between modalities during follow-up by Kaplan-Meier analysis (P=0.30). In this combined experience from 2 large health systems, TCAR was associated with less intraoperative complexity, as measured by operative time, radiation exposure, and contrast volume. Although stroke and death seemed to be less frequent in patients undergoing transcervical stenting, this did not reach statistical significance.