Outcomes of Transfemoral Carotid Artery Stenting and Transcarotid Artery Revascularization for Restenosis after Prior Ipsilateral Carotid Endarterectomy

OBJECTIVE Restenosis after carotid endarterectomy (CEA) poses unique therapeutic challenges, with no specific guidelines on operative approach. Traditionally, transfemoral carotid artery stenting (TfCAS) has been regarded as the preferred approach to treating restenosis after CEA. Recently, transcarotid artery revascularization with a flow-reversal neuroprotection system (TCAR) has gained popularity as an effective alternative treatment modality for de novo carotid artery stenosis. The aim of the study is to compare the contemporary perioperative outcomes of TfCAS and TCAR in patients with prior ipsilateral CEA. METHODS The Vascular Quality Initiative database was reviewed for patients undergoing TfCAS and TCAR for restenosis after prior ipsilateral CEA between January 2016 and August 2020. The primary outcome was 30-day composite outcome of stroke and death. Secondary outcomes included 30-day stroke, transient ischemic attack (TIA), myocardial infarction (MI), death and composite 30-day outcomes of stroke, death and TIA, stroke and TIA and death, stroke and TIA. Multivariable logistic regression models were used to evaluate outcomes of interest while adjusting for potential confounders and baseline differences between cohorts. RESULTS Out of 3,508 patients, 1,834 and 1,674 patients underwent TfCAS and TCAR, respectively. TCAR cohort was older (mean age 71.6 years vs 70.2 years; P<.001) and less likely to be symptomatic (27% vs 46%; P<.001), with a higher proportion of those taking aspirin (92% vs 88%; P=.001), P2Y 12 inhibitor (89% vs 80%; P<.001) and statin (91% vs 87%; P=.002), compared to TfCAS cohort. Perioperatively, TCAR cohort had lower 30-day composite outcomes of stroke/death (1.6% vs 2.7%; P=.025), stroke/death/TIA (1.8% vs 3.3%; P=.004) and stroke/death/MI (2.1% vs 3.2%; P=.048), primarily driven by lower rates of stroke (1.3% vs 2.3%; P=.031) and TIA (0.2% vs 0.7%; P=.031). Among asymptomatic patients, stroke (0.6% vs 1.4%; P=.042) and the composite of stroke/TIA (0.8% vs 1.8%; P=.036) were significantly lower after TCAR than TfCAS while TCAR was associated with lower TIA (0% vs 1%; P=.038) among symptomatic patients. On adjusted analysis, TCAR cohort had lower odds of TIA (adjusted odds ratio 0.17; 95% confidence interval, 0.04-0.74; P=.019). CONCLUSIONS Among patients undergoing carotid revascularization for restenosis following prior ipsilateral CEA, TCAR was associated with decreased odds of 30-day TIA compared to TfCAS. However, the two treatment approaches were similarly safe in terms of the remaining perioperative outcomes including stroke/death, stroke, death and MI. Our results support the safety and efficacy of TCAR in in this subset of patients deemed high risk for reintervention.
as reported in: J Vasc Surg. 2021 Sep 7 [Epub ahead of print]