Abstract
OBJECTIVE: In October 2023, CMS approved transfemoral carotid artery stenting (tfCAS) for standard-risk patients. Thus, we sought to compare outcomes among tfCAS, TCAR, and CEA in standard-risk and high-risk patients.
METHODS: All carotid revascularization procedures in the VQI following the CMS decision (October 2023-March 2025) were analyzed. Patients were classified as standard or high-risk per CMS criteria and stratified by symptom status. The primary outcome was perioperative stroke/death. Inverse probability of treatment weighting (IPTW) was performed to mitigate selection bias in high-risk patients and included demographics, comorbidities, physician volume, and operative characteristics. IPTW was also applied to symptomatic standard-risk patients to account for the large proportion of tfCAS cases performed outside of SVS guidelines.
RESULTS: Overall, 57,843 patients underwent revascularization (9,123 tfCAS, 21,814 TCAR, and 26,906 CEA). Before weighting, tfCAS patients were more often symptomatic (standard-risk: tfCAS: 45% vs. TCAR: 25% vs. CEA: 31%, P<.01; high-risk: 35% vs. 24% vs. 28%, P<.01), more frequently had a modified Rankin score of 4 or 5 (standard-risk: 7.7% vs. 2.4% vs. 1.7%; high-risk: 6.6% vs. 2.6% vs. 2.4%, P<.01) and more frequently underwent urgent or emergent surgery (standard-risk: 33% vs. 11% vs. 16%, high-risk: 28% vs. 12% vs. 17%, P<.01). Standard-risk asymptomatic patients undergoing tfCAS had the highest rates of perioperative stroke/death (1.6% vs. 1.2% vs. 1.0%, P=.01), as did symptomatic patients (2.9% vs. 1.9% vs. 1.7%, P=.01). tfCAS was associated with higher overall odds of stroke/death compared to CEA (OR 1.89 [1.43, 2.48] P<.01) and TCAR (OR 1.59 [1.15,2.18] P<.01). Compared to CEA tfCAS was associated with higher odds of stroke/death in both asymptomatic (OR 1.71 [1.12, 2.55] P=.01) and symptomatic patients (aOR 1.78 [1.21, 2.56] P<.01). After weighting, there were no significant differences in perioperative stroke/death overall for either tfCAS or TCAR compared to CEA in standard-risk symptomatic patients. In high-risk patients, TCAR was associated with lower odds of perioperative stroke/death overall compared to CEA (1.5% vs. 2.1%, aOR 0.75[0.59, 0.94] P=.01) while tfCAS had higher odds of stroke/death compared to TCAR. (1.5% vs. 2.4%, aOR 1.57 [1.25, 1.98] P<.01).
CONCLUSION: In this retrospective analysis, there were higher odds of perioperative stroke/death when comparing tfCAS to CEA overall and among asymptomatic and symptomatic standard-risk patients, as well as overall compared to TCAR. In high-risk patients, TCAR performed better with lower odds of stroke/death compared to both CEA and tfCAS.