TCAR outperforms transfemoral carotid artery stenting, ‘significantly’ lowering stroke and death risk

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A study that set out to determine whether there was a lesser stroke or death risk by deploying transcarotid artery revascularization (TCAR) over the transfemoral approach among patients receiving treatment for carotid stenosis suggested a statistically significant advantage for the former.

The researchers behind the analysis, led by Marc Schermerhorn, MD, chief of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston, uncovered a 1.6% vs. 3.1% level of risk in favor of TCAR when comparing the two methods of carotid artery stenting.

Schermerhorn et al carried out a propensity score-matched analysis of prospectively collected data from the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI), Transcarotid Revascularization Surveillance Project and Carotid Stent Registry of both asymptomatic and symptomatic patients in the United States and Canada who were receiving treatment via TCAR and transfemoral stenting for carotid stenosis from September 2016 to April 2019.

The study, published by JAMA: The Journal of the American Medical Association, involved 5,251 patients who underwent TCAR and 6,640 who received transfemoral stenting. After matching, 3,286 pairs of patients were identified.

The main finding—that TCAR was associated with a lower risk of in-hospital stroke or death (1.6% vs. 3.1%)—bore an absolute difference of -1.52% (95% CI, -2.29 to -0.75) and a relative risk (RR) of 0.51. Stroke alone yielded a risk comparison of 1.3% vs. 2.4%, an absolute difference of -1.10% (95% CI, -1.79 to -0.41) and an RR of 0.54, while death registered at 0.4% vs. 1.0% with an absolute difference of -0.55% (95% CI, -0.98 to -0.11) and an RR of 0.44.

“There was no statistically significant difference in the risk of perioperative myocardial infarction between the 2 cohorts (0.2% for transcarotid vs. 0.3% for the transfemoral approach; absolute difference, -0.09% [95% CI, -0.37 to 0.19]; RR, 0.70,” the researchers wrote.

Furthermore, at one year TCAR was again shown to provide lower risk of ipsilateral stroke or death (5.1% vs. 9.6%). However, the transcarotid method was associated with a higher risk of access site complication, resulting in interventional treatment (1.3% vs. 0.8%), the authors found. The transfemoral approach, on the other hand, resulted in more radiation.

The stakes are high. A number of trials have observed higher rates of perioperative stroke following transfemoral carotid artery stenting compared with carotid endarterectomy. The TCAR approach, which comes with flow reversal, was recently introduced for carotid stenting, the investigators pointed out, and specifically developed to decrease stroke risk. “However, its outcomes, compared with transfemoral carotid artery stenting, are not well characterized,” they wrote by way of introduction.

But the initial question—is TCAR or transfemoral carotid artery stenting associated with a lower risk of stroke or death among patients undergoing treatment for carotid artery stenosis?—got an answer.

“Among patients undergoing treatment for carotid stenosis, transcarotid artery revascularization, compared with transfemoral carotid artery stenting, was significantly associated with a lower risk of stroke or death,” the authors concluded.

SOURCE: DOI:10.1001/ JAMA.2019.18441

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