Strokes after transfemoral carotid artery stenting (TFCAS) were “the most disabling and lethal” when compared with transcarotid artery revascularisation (TCAR) and carotid endarterectomy (CEA) in a multicentre, retrospective analysis of Vascular Quality Initiative (VQI) data using modified Rankin Scale (mRS).
The study was recently published in press in the Journal of Vascular Surgery (JVS) by first author Mohammed Hamouda, senior author Mahmoud B Malas (both of UC San Diego, San Diego, USA) and colleagues following its initial presentation during a Vascular and Endovascular Surgery Society (VESS) session that took place at the 2025 Vascular Annual Meeting (VAM; 4–7 June, New Orleans, USA).
The VQI database was queried from September 2016–August 2024 for patients who suffered a postoperative stroke after their carotid revascularisation procedure, with the magnitude of the event quantified using mRS 0–6, where 0 is a stroke with no symptoms and 6 is a stroke leading to death. A severe stroke was defined as one having mRS>4.
Hamouda and colleagues found a total of 2,752 patients suffered a postoperative stroke after all three procedures. Overall, 22.5% of the postoperative strokes had mRS>4, the researchers discovered. When stratifying by procedure type, TFCAS had the highest rate of severe strokes—CEA 21.2% vs. TCAR 19.1% vs. TFCAS 30.7% (p<0.001). After adjusting for confounding variables, “there was no significant difference between TCAR and CEA in terms of odds of severe stroke, odds of a lethal stroke (mRS=6/dead) even after stratifying by symptomatic status (p>0.05),” they report. However, TFCAS-related strokes had 75% (adjusted odds ratio [aOR] 1.75, confidence interval [CI] 1.26–2.43), p<0.001) and 45% (aOR 1.45, CI 1.05–2.00, p=0.024) increased odds of being severe compared to CEA and TCAR, respectively.
“After stratifying by symptomatic status, there was no significant difference observed in asymptomatic patients; however, symptomatic TFCAS patients had more than double the odds (aOR 2.21, CI 1.47–3.33, p<0.001) of severe strokes compared to CEA and 72% increased odds of severe stroke (aOR 1.72, CI 1.12–2.67, p=0.014) compared to TCAR patients,” Hamouda and colleagues write in JVS.
Likewise, risk of dying following postoperative stroke was the highest with TFCAS—“the odds being 79% and 47% higher compared to CEA and TCAR, respectively”. In terms of one-year outcomes, patients who underwent TFCAS complicated by a stroke were at higher risk of recurrence and mortality compared to those getting a stroke after CEA, the investigators continue.
Similarly, TFCAS-related strokes were associated with “higher hazard of death during the first year of follow-up” compared to the TCAR group, but there was no difference in ipsilateral stroke recurrence. “Finally, there was no significant difference between TCAR and CEA in any of the one-year outcomes,” they add, with strokes after CEA and TCAR in the study “of a very similar magnitude in terms of postoperative functional outcomes as well how the index stroke impacts one-year recurrence or mortality”. Concluding, Hamouda and colleagues note, “CEA exhibited the highest unadjusted stroke-free survival rate” among the three procedures.
