December 17, 2019
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TCAR superior to transfemoral carotid stenting for stroke, death

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Marc L. Schermerhorn

Compared with transfemoral carotid artery stenting, transcarotid artery revascularization with flow reversal was associated with lower rates of stroke and death in patients with carotid artery stenosis, according to a propensity score-matched analysis published in JAMA.

The researchers matched 3,286 pairs of patients who underwent transfemoral carotid artery stenting or transcarotid artery revascularization (TCAR) with flow reversal (Enroute, Silk Road Medical) between September 2016 and April 2019 and were included in the Vascular Quality Initiative Transcarotid Artery Surveillance Project and Carotid Stent Registry.

Compared with transfemoral CAS, TCAR conferred lower rates of in-hospital stroke or death (1.6% vs. 3.1%; absolute difference, 1.52%; 95% CI, 2.29 to 0.75; RR = 0.51; 95% CI, 0.37-0.72), in-hospital stroke (1.3% vs. 2.4%; absolute difference, 1.1%; 95% CI, 1.79 to 0.41; RR = 0.54; 95% CI, 0.38-0.79) or in-hospital death (0.4 % vs. 1%; absolute difference, 0.55%; 95% CI, 0.98 to 0.11; RR = 0.44; 95% CI, 0.23-0.82), Marc L. Schermerhorn, MD, chief of the division of vascular and endovascular surgery at Beth Israel Deaconess Medical Center, and colleagues wrote.

Perioperative MI did not differ between the groups (TCAR, 0.2%; transfemoral CAS, 0.3%; RR = 0.7; 95% CI, 0.27-1.84), according to the researchers.

According to a Kaplan-Meier life-table estimation, at 1 year, TCAR was associated with reduced risk for ipsilateral stroke or death compared with transfemoral CAS (5.1% vs. 9.6%; HR = 0.52; 95% CI, 0.41-0.66).

TCAR was associated with higher rates of access-site complications requiring intervention (1.3% vs. 0.8%; RR = 1.63; 95% CI, 1.02-2.61), but transfemoral CAS was associated with greater use of radiation (median fluoroscopy time, 5 minutes vs. 16 minutes; P < .001) and contrast (median contrast used, 30 mL vs. 80 mL; P < .001), Schermerhorn and colleagues wrote.

The patients were matched from a cohort of 5,251 patients who had TCAR and 6,640 who had transfemoral CAS. After matching, in both groups, the mean age was 72 years and 35% of patients were women. The frequency of TCAR procedures rose over time, according to the researchers.

“As a response to the high rates of perioperative stroke with transfemoral carotid artery stenting, transcarotid revascularization with flow reversal was developed as a new carotid stenting technique, specifically to avoid the high-risk maneuvers that have been associated with transfemoral carotid artery stenting, including manipulation of the aortic arch to cannulate the common carotid artery and crossing the carotid lesion unprotected to deploy the embolic protection filter distally,” Schermerhorn and colleagues wrote. – by Erik Swain

Disclosures: Schermerhorn reports he received personal fees for provision of consultancy services from Abbott, Cook, Endologix, Medtronic and Silk Road Medical. Please see the study for all other authors’ relevant financial disclosures.