An increased postoperative stroke rate associated with transfemoral carotid artery stenting “seems to extend up to five years’ follow-up” compared to carotid endarterectomy. This is the conclusion set to be presented by Kevin S. Yei, BS, of the University of California San Diego, at the Society for Vascular Surgery (SVS) Vascular Annual Meeting (VAM). Yei is delivering a talk on the long-term outcomes of carotid endarterectomy (CEA) vs. transfemoral carotid artery stenting in the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION).
Contextualizing this research, Yei and colleagues explain that CEA “remains the gold-standard revascularization procedure for patients with high-grade carotid artery stenosis.”
Transfemoral carotid artery stenting, he will tell SVS attendees, was introduced as a minimally invasive alternative procedure in patients who are deemed high-risk for endarterectomy.
While earlier studies had shown an increased risk of perioperative stroke in transfemoral carotid artery stenting versus endarterectomy, Yei says that, prior to his team’s recent work, the long-term implications of the perioperative differences of these two procedures “had not been completely studied.”
The investigators therefore analyzed all cases in the CEA and carotid artery stenosis files in VQI-VISION from 2003–2016. Kaplan-Meier analysis, log-rank tests, and Cox-regression were utilized to compare stroke, death, and stroke/death at one, five, and 10 years.
In total, 58,840 carotid revascularizations were performed, 52,050 (87.8%) of which were endarterectomies, and 7,264 (12.2%) of which were transfemoral carotid artery stenting procedures. Patients undergoing the latter were more likely to be younger, male, and non-white. They were also more likely to have comorbidities, a history of prior vascular intervention, and symptoms at presentation.
On adjusted analysis, the researchers found that transfemoral carotid artery stenting had significantly higher rates of stroke/death across 10 years of follow-up (after one year: adjusted hazard ratio [aHR], 1.70; 95% confidence interval [CI], 1.53–1.87, p<0.001; after five years: aHR, 1.46; 95% CI, 1.32–1.62, p<0.001; after 10 years: aHR, 1.4, 95% CI, 1.28–1.57, p<0.001). Transfemoral carotid artery stenting also had higher rates of stroke at one-year (aHR, 1.74, 95% CI, 1.48–2.04, p<0.001) and five-year follow-up (aHR, 1.25, 95% CI, 1.02–1.54, p<0.001), but not at 10-year follow-up (aHR, 1.19, 95% CI, 0.97–1.47, p=0.096).
Furthermore, transfemoral carotid artery stenting also had higher rates of death across the 10 years of follow-up (one-year follow-up: aHR, 1.73, 95% CI, 1.55–1.94, p<0.001; five-year follow-up: aHR, 1.47, 95% CI, 1.33–1.62, p<0.001; 10-year follow-up: aHR, 1.4, 95% CI, 1.26–1.56, p<0.001).
“After adjusting for potential confounders, the increased postoperative stroke rate associated with transfemoral carotid artery stenting compared to carotid endarterectomy seems to extend up to five years of follow-up,” write Yei and colleagues in the abstract to be presented at VAM. “Transfemoral carotid artery stenting is also associated with decreased survival compared to carotid endarterectomy up to 10 years of follow-up.
“This study shows improved long-term durability of [CEA] compared to transfemoral carotid artery stenting for [the] treatment of carotid artery stenosis in a large-scale, real-world database.”
Yei et al add that future comparisons with transcarotid artery revascularization (TCAR) will be required as long-term follow-up data for this procedure becomes available.