RS04 - Risk of Reintervention Is Lower for Carotid Endarterectomy Than Carotid Artery Stenting

Objectives: Perioperative outcomes for carotid endarterectomy (CEA) and carotid artery stenting (CAS) have been well studied. Less is known about the durability and reintervention rates of each, particularly in the era of transcarotid artery revascularization (TCAR). We sought to compare real-world rates of ipsilateral reintervention, stroke, and death in patients undergoing CEA and CAS, with an additional analysis of CAS patients comparing reintervention between transfemoral stenting (TFCAS) and TCAR.

Methods: The Vascular Quality Initiative (VQI) was matched to Medicare claims via the Vascular Implant Surveillance and Implantation Network (VISION) database, and we identified patients who had primary carotid revascularization from December 2016 to December 2019. The primary outcome was ipsilateral reintervention, while secondary outcomes included stroke and mortality. After 1:1 greedy matching using propensity scores, patients who underwent CEA and CAS were compared within 6 months following the index procedure and from 6 months to 3 years separately using time-dependent Cox regression models. A separate propensity matched analysis was then performed to compare TFCAS and TCAR. Kaplan-Meier curves were compared using log rank tests.

Results: We identified 27944 patients undergoing CEA (n=21256) or CAS (n=6688). After propensity matching, we compared 4705 patients in each group. Risk of re-intervention was increased within 6 months for CAS (HR: 1.97; CI: 1.11-3.50; p< 0.05), but not beyond 6 months (HR: 1.08; CI: 0.62-1.89; p=0.79). The incidence of stroke prior to discharge was increased in patients undergoing CAS (5.4% v. 1.0%; p< 0.0001), and similarly was increased within 6 months (HR: 2.91; CI: 2.42-3.48; p< 0.0001) but not beyond 6 months. However, mortality for CAS was increased both within 6 months (HR:1.69; CI: 1.38-2.07; p< 0.0001) and beyond 6 months (HR: 1.52; CI: 1.27-1.81; p< 0.0001). When comparing TFCAS and TCAR (n=2115 per group), there was a significantly increased risk of re-intervention for TFCAS beyond 6 months (HR: 2.31, CI: 1.05-5.11, p < 0.05), but not within 6 months (HR:1.56, CI: 0.71-3.43, p = 0.27) (Figure 1).

Conclusions: CEA portends a lower risk of reintervention than CAS, particularly within the first 6 months after intervention. We also confirm prior data suggesting lower rates of ipsilateral stroke and death with CEA compared to CAS. On subgroup analysis of stenting modalities, TCAR had a lower rate of reintervention than TFCAS. CEA appears to be the most durable carotid revascularization strategy, with TCAR being more durable among stenting procedures.