1. In this retrospective cohort study, among 2962 patients with standard surgical risk who underwent transcarotid artery revascularization and 8886 patients who underwent carotid endarterectomy, there was no significant difference in risk of 30-day stroke, death, and myocardial infarction or 1-year ipsilateral stroke.

2. Transcarotid artery revascularization was associated with a higher risk of 1-year ipsilateral stroke when compared with carotid endarterectomy (1.6 vs 1.1%), but no difference in 1-year all-cause mortality was found (2.6% vs 2.5%).

Evidence Rating Level: 2 (Good)

Study Rundown: Transcarotid artery revascularization is a newer technique used to treat coronary artery stenosis involving carotid stenting with direct access to the common carotid artery. Several trials have found that transfemoral carotid artery stenting poses a higher risk of stroke or death when compared with carotid endarterectomy in symptomatic and elderly patients. This study aimed to compare stroke, death, and myocardial infarction outcomes in patients undergoing transcarotid artery revascularization vs carotid endarterectomy. This retrospective-propensity-matched cohort study included 2962 patients undergoing transcarotid artery revascularization, and 8886 patients undergoing carotid endarterectomy for atherosclerotic carotid disease between August 2016 to August 2019. The primary outcome was a composite endpoint of 30-day stroke, death, myocardial infarction, or 1-year ipsilateral stroke. No statistically significant difference in risk of 30-day stroke, death, and myocardial infarction was found between the two cohorts. Transcarotid artery revascularization was associated with a higher risk of 1-year ipsilateral stroke (1.6% vs 1.1%); however, it was also associated with a significantly lower rate of cranial nerve injury compared to endarterectomy. A major strength of this study was its large sample size. A limitation was the potential for selection bias due to the nonrandomized nature of the study design, which allowed for the treating physician to determine the procedure based on personal expertise and clinical judgement.

Click to read the study in JAMA Neurology

Click to read an accompanying editorial in JAMA Neurology

Relevant Reading: Early outcomes in the ROADSTER 2 study of transcarotid artery revascularization in patients with significant carotid artery disease

In-Depth [prospective cohort]: This study investigated the association of stroke, death and myocardial infarction outcomes in patients receiving transcarotid artery revascularization vs carotid endarterectomy for atherosclerotic carotid disease. The main exposures were transcarotid artery revascularization vs carotid endarterectomy. The primary outcome was a composite endpoint of 30-day stroke, death, myocardial infarction, or 1-year ipsilateral stroke. A total of 2962 patients undergoing transcarotid artery revascularization, and 8886 patients undergoing carotid endarterectomy were identified from the multicenter Vascular Quality Initiative Carotid Artery Stent and Carotid Endarterectomy registries, and propensity-matched 1:3. The in-hospital composite risk of stroke, death, or myocardial infarction was 2.0% for transcarotid artery revascularization and 1.7% for carotid endarterectomy (absolute difference, 0.26% [95% CI, -0.31% to 0.82%]; P = .35), a difference that was not statistically significant. Additionally, no significant differences in death (0.2% vs 0.2%; absolute difference, 0.04% [95% CI, -0.14% to 0.23%]; P = .61, or myocardial infarction (0.5% vs 0.7%; absolute difference, -0.24% [95% CI, -0.54 to 0.06%]; P = .17). Transcarotid artery revascularization was associate with a higher risk of stroke (1.5% vs 1.0%; absolute difference, 0.46% [95% CI, 0.01% to 0.94%]; P = .04). Transcarotid artery revascularization was however, associated with a significantly lower rate of cranial nerve injury (0.3% vs 2.7%; absolute difference, -2.4% [95%CI, -2.8 to -2.0]; P < .001) and shorter mean (SD) operative times (72.2 [29.4] minutes vs 117 [43.7] minutes; P < .001). There was no significant difference in the risk of primary composite endpoint between the two cohorts (transcarotid 3.0% vs endarterectomy 2.6%; absolute difference, 0.40% [95%CI, -0.43% to 1.24%]; relative risk [RR], 1.14 [95%CI, 0.87 to 1.50]; P =.34). Transcarotid artery revascularization was associated with a higher risk of ipsilateral stroke (1.6% vs 1.1%; absolute difference, 0.52% [95% CI, 0.03 to 1.08]; RR, 1.49 [95% CI, 1.05% to 2.11%]; P = .02), but no difference in 1-year all-cause mortality was found (2.6% vs 2.5%; absolute difference, -0.13% [95%CI, -0.18% to 0.33%]; RR, 1.04 [95% CI, 0.78 to 1.39]; P = .67).

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