Early and Intermediate Clinical Outcome of Trans carotid Artery Revascularization vs Carotid Endarterectomy from a Large Single Center Experience
Ali F AbuRahma1, Adrian Santini1, Zachary AbuRahma1, Andrew Lee1, Christina Veith1, Noah Dargy1, Robert Cragon1, Scott Dean2, Elaine Mattox2
1Charleston Area Medical Center/West Virginia University Charleston Division, Charleston, WV;2Charleston Area Medical Center Health Education and Research Institute, Charleston, WV
Background/Purpose: Trans carotid artery revascularization (TCAR) has been practiced as an alternative for both carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) specifically in high-risk patients. More recently CMS expanded coverage for TCAR in standard surgical risk patients if done within the SVS/vascular quality initiative (SVS/VQI) TCAR surveillance project. A few registry studies (primarily from SVS/VQI) compared the early and up to one year outcome of TCAR vs CEA or TFCAS. There is no large single center study that reported late clinical outcome. This present study will compare intermediate clinical outcome of TCAR vs CEA.Patient Population and Methods: This study analyzed prospectively collected data from TCAR surveillance project patients enrolled in our institution and compare it with CEA patients done by the same providers at the same time period. The primary outcome was combined perioperative stroke/death and late stroke/death. Secondary outcome included combined stroke, death and MI, cranial nerve injury (CNI), and bleeding. Propensity matching was done to analyze outcome. Kaplan Myer analysis was used to estimate freedom from stroke, stroke/death, ≥50% and ≥80% restenosis.Results: 646 procedures (637 patients) (404 CEA, 242 TCAR) were analyzed. There was no significant difference in indications for carotid intervention. However, TCAR patients had more high-risk criteria including hypertension, coronary artery disease, congestive heart failure, and renal failure. There was no significant differences between CEA vs TCAR in 30-day perioperative stroke (1% vs 2%), stroke/death rate (1% vs 3%, p=0.0849), or major hematomas (2% vs 2%). The rate of CNI was significant (5% for CEA vs 1% for TCAR, p=0.0138). After matching 242 CEAs vs 242 TCARs, perioperative stroke rate was 1% for CEA vs 2% for TCAR (p=0.5037), stroke/death rate (2% vs 3%, p=0.2423), and CNI (3% vs 1%, p=0.127) were similar. At late follow up (2 years) there were significant differences between CEA vs TCAR in rates of stroke, 0.8% vs 4% (p=0.0242), stroke/death, 8% vs 15% (p=0.0345), and ≥80% stenosis, 0.9% vs 4% (p=0.006). The rates of freedom from stroke at 6, 12, 18, and 24 months for CEA vs TCAR were: 99%, 99%, 99%, and 99% vs 97%, 95%, 93% and 93%; p=0.0345 (Fig 1), stroke/death: 95%, 90%, 88%, and 85% vs 93%, 87%, 76%, and 75%; p=0.0455 (Fig 2), and ≥80% restenosis: 100%, 99%, 98%, and 98% vs 97%, 95%, 93%, and 91%; p=0.0562, respectively.
Conclusion: In propensity match analysis, both CEA and TCAR have similar perioperative clinical outcomes. However, CEA was superior to TCAR for the rates of late stroke, stroke/death, and ≥80% restenosis at 2 years.
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