A large, single-centre analysis has found that, despite parity between the two procedures in terms of perioperative clinical outcomes, carotid endarterectomy (CEA) was associated with a reduced rate of late stroke/death compared to transcarotid artery revascularisation (TCAR).
Writing in the Journal of Vascular Surgery (JVS), Ali AbuRahma (Charleston Area Medical Center/West Virginia University, Charleston, USA) and colleagues also conclude that CEA produced a marginally lower rate of restenosis ≥80% at two years—although this difference did not reach statistical significance.
The authors initially note that multiple registry studies—primarily ones conducted within the Society for Vascular Surgery’s (SVS) Vascular Quality Initiative (VQI)—have compared early outcomes, and outcomes up to one year, between TCAR, CEA and carotid artery stenting (CAS). However, no large, single-centre studies have reported on late clinical outcomes between these procedures and, as such, they conducted a retrospective analysis comparing intermediate outcomes with TCAR versus CEA.
Their study analysed data collected from the TCAR Surveillance Project on patients at the Charleston Area Medical Center, with these data being compared and subsequently propensity matched against patients undergoing CEA. Patients in both groups were treated by the same providers across the same time period, the authors note.
The primary outcome of the analysis was a combination of perioperative stroke/death and late stroke/death rates, while secondary outcomes included combined stroke/death/myocardial infarction (MI), cranial nerve injury (CNI), and bleeding. Kaplan-Meier analyses were used to estimate patients’ freedom from stroke, stroke/death, and also rates of restenosis ≥50% and ≥80%.
Across 637 patients, a total of 646 procedures (404 CEAs and 242 TCARs) were analysed, with AbuRahma and colleagues finding no significant differences in indications for carotid intervention between these two groups—although TCAR patients had more high-risk criteria including hypertension, coronary artery disease, congestive heart failure, and renal failure.
The authors report that there was no significant difference between CEA and TCAR in terms of the rates of 30-day perioperative stroke (1% vs. 2%, respectively), stroke/death (1% vs. 3%), or major haematoma (2% vs. 2%). However, the rate of early CNI was found to be significantly higher with CEA (5%) versus TCAR (1%; p=0.0138). In addition, late follow-up analyses at two years revealed results favouring CEA over TCAR, as the former produced lower rates of stroke (1% vs. 4%, respectively; p=0.0273), stroke/death (8% vs. 15%; p=0.008), and restenosis ≥80% (0.5% vs. 3%; p=0.0139).
AbuRahma and colleagues’ propensity-matched analysis, under which 242 CEAs and 242 TCARs were included, found broadly similar perioperative outcomes regarding stroke rate (CEA, 1% vs. TCAR, 2%), stroke/death rate (CEA, 2% vs. TCAR, 3%) and CNI rate (CEA, 3% vs. TCAR, 1%). Once again, however, their later follow-up analysis generally favoured CEA, as demonstrated by a rate of stroke of 1%—compared to 4% with TCAR (p=0.0615)—and a rate of stroke/death of 8%—compared to 15% with TCAR (p=0.0345).
Finally, the authors also note a marginally smaller difference in the occurrence of restenosis ≥80% following propensity matching, as compared to their regular analysis, with rates of 0.9% associated with CEA versus 3% with TCAR (p=0.099). This difference was not deemed statistically significant, they add, and rates of restenosis ≥50% were not statistically significantly different between the two procedures either.
“In propensity-matched analysis, both CEA and TCAR have similar perioperative clinical outcomes. However, CEA was superior to TCAR for the rates of late stroke/death and had somewhat lower rates of ≥80% restenosis at two years,” AbuRahma told NeuroNews, outlining the salient message from the paper. “The type of intervention, CEA versus TCAR, should depend on risk stratification—anatomical and/or physiological.”
Interesting work. Congratulations to the Charleston team for the evaluation. Is there any vessel that, in the long run, does better with a metal scaffold applying radial force to the wall?