Researchers led by a vascular team in Indianapolis found that carotid endarterectomy (CEA) remains the most-used strategy in carotid revascularization, with CEA and transcarotid artery revascularization (TCAR) showing decreased odds of stroke or death compared to transfemoral carotid artery stenting (TF-CAS).
Those were among the main findings delivered by Hanaa Dakour Aridi, MD, an integrated vascular surgery resident at Indiana University in Indianapolis, during the 2022 annual meeting of the Midwestern Vascular Surgical Society (MVSS) in Grand Rapids, Michigan (Sept. 15–17), after a analysis of regional variation in patient selection, practice patterns and outcomes based on techniques used in carotid revascularization logged in the Vascular Quality Initiative (VQI) from 2016–2021.
The research team divided 19 geographic regions into three quantiles based on the average annual volume of carotid procedures performed: low (956 cases), medium (1,533) and high (1,845) centers. They looked at a total of 126,768 carotid revascularization cases, with most patients asymptomatic. CEA was the most common procedure (>60%) across all regional groups, with 13% performed using TF-CAS and 17% with TCAR.
“Overall, there was a trend towards increased utilization of TCAR since its introduction in 2016 up to 2021,” Aridi told MVSS 2022. “This seems to have been mirrored by an increase in the percentage of CEA cases.”
Aridi reported the research team found no significant differences in stroke and death between CEA and TCAR across the three regional volume groups. “However, TF-CAS was associated with a higher odds of stroke and death compared to CEA, and TCAR was associated with a decreased odds of stroke or death compared to TF-CAS,” she said. “These variations were also seen when we analyzed the regions individually.”
Despite significant variation in clinical practice, Aridi concluded, “no significant regional variation was observed in the outcomes of carotid revascularization. TCAR and CEA continue to show superior outcomes to TF-CAS across all regional groups. Our study identifies some gaps in adherence to societal guidelines, mainly in terms of intraoperative procedural variability that can potentially lead to worse outcomes. It also highlights the need for uniformity in management of patients with carotid artery disease.”
Raghu Motaganahalli, MD, the study’s senior author, told Vascular Specialist: “What we are seeing is TCAR has grown at the cost of CEA, not at the cost of TF-CAS,” further noting, “We would love to see growth happening at the cost of TF-CAS because it is probably at a higher risk of stroke and complications.”