Outcomes of Transcarotid Artery Revascularization Versus Transfemoral Carotid Artery Stenting Based on Aortic Arch Type and Degree of Atherosclerosis

• DOI: 10.1016/j.jvs.2024.03.263
• Publication Date: 2024-05-20T06:34:15Z
• Authors: Mohammed Hamouda; Shaima Alqrain; Sina Zarrintan; Kevin Yei; Andrew R. Barleben; Mahmoud Malas

Transfemoral carotid artery stenting (TFCAS) was currently approved for reimbursement by the Centers Medicare and Medicaid Services (CMS) treatment of standard risk patients. TFCAS in patients with complex aortic arch anatomy is known to be challenging worse outcomes, transcarotid revascularization (TCAR) could a preferable alternative anatomy. We aim compare outcomes TCAR versus across all types degrees atherosclerosis. All undergoing between September 2016 October 2023 were identified VQI database. Patients stratified into four groups: Group A: mild atherosclerosis type I/II arch; B: III C: moderate/severe D: arch. The primary outcome in-hospital composite stroke or death. Analysis variance χ2 tests analyzed differences baseline characteristics. Logistic regression models adjusted potential confounders, backward stepwise selection implemented identify significant variables inclusion final models. A total 20,114 included (Group 12,980; 64.53%; 1175; 5.84%; 5124; 25.47%; 835; 4.15%) (Table I). more commonly performed groups (72.21%, 67.06%, 74.94%, 69.22%; p < .001). Compared atherosclerosis, advanced C D likely female, hypertensive, smokers, have CKD. B present preoperatively. On multivariable analysis, had less than one-half stroke/death 1-year mortality compared mildest simple A) (OR, 0.43; 95% CI, 0.31-0.61; P< .001; HR, 0.42; 0.32-0.57; P .001) II). similar but 70% lower odds 0.30; 0.12-0.75; = .01). Similar findings also evident severe 0.66; .037). D) showed same outcome, it not statistically 0.91; .834). safer only disease anatomy, configuration. Current CMS decision will increase death nationally.Table IBaseline characteristics degree atherosclerosisGroup I-II arch, No. (%)Group moderate (%)P value12,980 (64.53)1175 (5.84)5124 (25.47)835 (4.15)Age, years71.77 (9.10)75.00 (8.41)73.85 (8.49)76.33 (8.27)<.001Obesity (BMI >30 kg/m2)4634 (35.75)293 (24.96)1699 (33.24)193 (23.42)<.001Sex (Female)4474 (34.47)452 (38.47)2072 (40.44)374 (44.79)<.001Race (Non-White)1192 (9.19)97 (8.26)520 (10.15)64 (7.66).033Ethnicity (Hispanic Latino)585 (4.52)37 (3.15)195 (3.81)47 (5.63).008Insurance (Medicare)8770 (67.61)903 (76.85)3681 (71.91)658 (78.90)<.001Symptomatic status Amaurosis fugax687 (5.29)61 (5.19)236 (4.61)36 (4.31).198 TIA1550 (11.94)124 (10.55)573 (11.18)101 (12.10).299 Stroke2874 (22.14)277 (23.57)1041 (20.32)211 (25.27).001Comorbidities Diabetes4957 (38.19)347 (29.53)2068 (40.38)265 (31.74)< .001 HTN11,654 (89.78)1059 (90.13)4741 (92.60)775 (93.04)<.001 CHF2090 (16.10)176 (14.98)1003 (19.59)166 (19.88)<.001 COPD2998 (23.10)315 (26.83)1588 (31.02)263 (31.50)<.001 CKD4337 (33.88)391 (33.62)1957 (39.29)306 (38.25)<.001 Dialysis140 (1.08)9 (0.77)93 (1.82)16 (1.92)<.001 ASA class IV-V3093 (24.21)300 (26.11)1468 (29.14)240 (29.02)<.001Prior procedures Prior CABG/PCI4880 (37.60)399 (33.96)2128 (41.54)303 (36.29)<.001 major amputation265 (2.04)15 (1.28)113 (2.21)16 (1.92).241 ipsilateral CEA/CAS1977 (15.24)139 (11.83)751 (14.66)115 (13.77).012 contralateral CEA/CAS1902 (14.66)166 (14.13)903 (17.63)147 (17.60)<.001 Ipsilateral stenosis >80%5016 (48.18)396 (45.67)1953 (47.88)304 (50.00).390 Contralateral occlusion1039 (9.34)73 (7.90)532 (12.21)74 (11.23)<.001 Bovine arch1369 (10.58)121 (10.34)527 (10.33)81 (9.72).104 Elective10,797 (83.19)986 (83.91)4373 (85.34)674 (80.72)<.001Smoking history smoker6129 (47.24)552 (47.02)2690 (52.55)428 (51.26)<.001 smoker2949 (22.73)267 (22.74)1322 (25.83)200 (23.95)<.001 General anesthesia8492 (65.44)646 (55.03)3408 (66.51)457 (54.73)<.001Preoperative medication P2Y inhibitor11,461 (88.31)1033 (87.91)4528 (88.42)745 (89.33).793 Statin11,645 (89.73)1047 (89.18)4610 (90.04)755 (90.42).746 Aspirin11,789 (90.82)1066 (90.72)4601 (89.83)746 (89.34).130 Beta-blocker6934 (53.44)600 (51.15)2926 (57.13)472 (56.53)<.001 RAAS inhibitor6917 (53.30)590 (50.21)2793 (54.53)440 (52.69).054 Anticoagulant1801 (13.88)169 (14.38)829 (16.19)130 (15.57).001ASA, American Society Anesthesiologists; CABG, coronary bypass graft; CAS, stenting; CEA, endarterectomy; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, obstructive pulmonary PCI, percutaneous intervention; TIA, transient ischemic attack. Open table new tab Table IIOutcomes vs ATCAR TFCASGroup BTCAR CTCAR DTCAR TFCASOR/HR (95% CI)P valueOR/HR CI)P-valueOR/HR valueIn-hospital Stroke/TIA0.59 (0.46-0.77)<.0010.44 (0.18-1.06).0660.69 (0.45-1.04).0741.07 (0.45-2.55).872 Stroke/death0.43 (0.31-0.61)<.0010.30 (0.12-0.75).0100.66 (0.44-0.97).0370.91 (0.39-2.16).834 Stroke/death/MI0.52 (0.38-0.72)<.0010.38 (0.17-0.85).0180.71 (0.49-1.02).0640.75 (0.36-1.58).451 Length stay (> 1 day)0.71 (0.60-0.83)<.0010.80 (0.58-1.10).1750.89 (0.70-1.13).3230.43 (0.23-0.79).006Follow-up mortality0.42 (0.32-0.57)<.0011.06 (0.49-2.30).8760.85 (0.61-1.19).3401.22 (0.64-2.32).546CI, Confidence onterval; hazard ratio; MI, myocardial infarction; OR, attack.Boldface indicates statistical significance.