Three-year risk of stroke after transcarotid artery revascularization versus carotid endarterectomy among Medicare beneficiaries.

backgroundTranscarotid artery revascularization (TCAR) has seen widespread adoption in contemporary practice. However, the risk of stroke after TCAR vs carotid endarterectomy (CEA) beyond the perioperative period remains poorly defined. Our objective was to compare the 3-year risk of stroke after TCAR vs CEA.

methodsWe performed a retrospective cohort study using data from the Vascular Implant Surveillance and Outcomes Network (VISION), a procedural registry linked to Medicare claims data that captures clinical, procedural, and outcomes data on patients who underwent carotid revascularization. We studied patients who underwent TCAR or CEA and were part of the VISION database between October 1, 2016 (start of TCAR surveillance registry), and December 31, 2019 (end of linked Medicare claims availability). The primary exposure was surgery type (TCAR or CEA). The primary outcome was stroke, defined using a validated claims code list, and death. Asymptomatic and symptomatic patients were analyzed separately. We used Kaplan-Meier analysis and Cox regression for risk adjustment. We used competing-risk and propensity score methods for sensitivity analyses.

resultsThere were 19,141 asymptomatic (TCAR, 3482; CEA, 15,659) and 12,343 symptomatic (TCAR, 2 377; CEA, 9966) patients who underwent carotid surgery. Patients who underwent TCAR were older, more likely to be female, and more likely to be anatomical high risk. Among asymptomatic patients, the 3-year risk of stroke was similar after TCAR (5.1%; 95% CI, 3.0%-7.1%) and CEA (4.9%; 95% CI, 4.4%-5.4%; log-rank P = .93). The composite 3-year risk of stroke or death was 22.6% (95% CI, 18.8%-26.3%) after TCAR and 20.0% (95% CI, 18.8%-21.2%) after CEA (log-rank P < .001). Compared with CEA, the adjusted HR of stroke after TCAR among asymptomatic patients was 1.10 (95% CI, 0.82-1.49). Among patients with symptomatic carotid stenosis, the 3-year risk of stroke was also similar between TCAR (16.6%; 95% CI, 12.1%-20.9%) and CEA (13.6%; 95% CI, 12.5%-14.7%; log-rank P = .17). The composite 3-year risk of stroke or death risk was 35.9% (95% CI, 30.1%-41.2%) after TCAR and 30.0% (95% CI, 28.3%-31.7%) after CEA (log-rank P < .001). Compared with CEA, the adjusted HR for stroke after TCAR among symptomatic patients was 1.00 (95% CI, 0.75-1.33).

conclusionsIn this comparative effectiveness study, TCAR had a similar risk of stroke to CEA. This was durable over 3 years of follow-up and was consistent among asymptomatic and symptomatic patients. These results can inform procedure choices for patients and providers when considering carotid surgery and help to inform requisite shared decision-making before intervention.