Abstract
OBJECTIVE: In October 2023, Centers for Medicare & Medicaid Services (CMS) approved transfemoral carotid artery stenting (tfCAS) for standard-risk patients. Thus, we sought to compare outcomes among tfCAS, transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) in standard-risk and high-risk patients.
METHODS: All carotid revascularization procedures in the Vascular Quality Initiative after the CMS decision (October 2023-March 2025) were analyzed. Patients were classified as standard-risk or high-risk per CMS criteria and stratified by symptom status. The primary outcome was perioperative stroke/death. Inverse probability of treatment weighting was performed to mitigate selection bias in high-risk patients and included demographics, comorbidities, physician volume, and operative characteristics. Inverse probability of treatment weighting was also applied to symptomatic standard-risk patients to account for the large proportion of tfCAS cases performed outside of Society for Vascular Surgery guidelines.
RESULTS: Overall, 57,843 patients underwent revascularization (9123 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 with CEA (odds ratio [OR]: 1.89 [1.43, 2.48], P < .01) and TCAR (OR: 1.59 [1.15, 2.18], P < .01). Compared with 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 (adjusted OR [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 with CEA in standard-risk symptomatic patients. In high-risk patients, TCAR was associated with lower odds of perioperative stroke/death overall compared with CEA (1.5% vs 2.1%, aOR: 0.75 [0.59, 0.94], P = .01), whereas tfCAS had higher odds of stroke/death compared with TCAR (1.5% vs 2.4%, aOR: 1.57 [1.25, 1.98], P < .01).
CONCLUSIONS: In this retrospective analysis, there were higher odds of perioperative stroke/death when comparing tfCAS with CEA overall and among asymptomatic and symptomatic standard-risk patients, as well as overall compared with TCAR. In high-risk patients, TCAR performed better with lower odds of stroke/death compared with both CEA and tfCAS.