Transcarotid artery revascularization confers better outcomes than transfemoral CAS

Compared with carotid artery stenting via the transfemoral approach, transcarotid artery revascularization leads to better neurologic and mortality outcomes in patients with carotid stenosis, according to data presented at the Society for Vascular Surgery Vascular Annual Meeting.

Researchers compared patients who underwent transcarotid artery revascularization (TCAR), which involves direct access via the carotid artery and cerebral protection with a flow-reversal system (Enroute, Silk Road Medical), and were enrolled in the SVS Vascular Quality Initiative TCAR Surveillance Project, with patients in the Vascular Quality Initiative who underwent transfemoral CAS.

The researchers conducted a univariate analysis comparing 638 patients who had TCAR with 10,136 patients who had transfemoral CAS, and a propensity score-matched analysis of 471 patients in both groups. Matching was based on age, race, CAD, congestive HF, prior CABG/PCI, chronic kidney disease, diabetes, American Society of Anesthesiologists physical class, symptomatic status, restenosis, anatomical and medical risk, emergency status and preoperative medication use.

The primary outcome was in-hospital mortality/stroke/transient ischemic attack.

Mahmoud Malas, MB, MD , MHS , professor of surgery and epidemiology and director of the Center for Research Excellence and Surgical Trials at Johns Hopkins Medical Institutes, and colleagues found that the primary outcome was less frequent in the TCAR group (2.2% vs. 3.8%; OR = 2.23; 95% CI, 1.08-4.62).

In-hospital stroke/TIA was also lower in the TCAR group (1.9% vs. 3.3%; OR = 2.39; 95% CI, 1.11-5.14), whereas there was no difference between the groups in in-hospital stroke (TCAR, 1.4%; transfemoral CAS, 2%; OR = 2.18; 95% CI, 0.82-5.77) or in-hospital MI (TCAR, 1.1%; transfemoral CAS, 0.6%; OR = 1.13; 95% CI, 0.3-4.25), Malas said during a presentation.

Results were similar in the propensity-matched analysis.

The study demonstrated “satisfactory initial in-hospital outcomes after TCAR with dynamic flow reversal in patients who were not only at high risk for [carotid endarterectomy], but also a highly comorbid group of patients that might be at high risk for [transfemoral] CAS,” Malas said during the presentation. “TCAR is a promising hybrid procedure with excellent outcomes.”

Longer-term studies are needed to draw more definitive conclusions, he said. – by Erik Swain

References:

Malas MB, et al. S5: Scientific Session 5. Presented at: Society for Vascular Surgery Vascular Annual Meeting; June 20-23, 2018; Boston.

Malas MB, et al. J Vasc Surg. 2018;doi:10.1016/j.jvs.2018.05.011.

Disclosure: Malas reports he is a consultant for Silk Road Medical and has served as an investigator for several trials sponsored by Silk Road Medical.