IFT08 - Comparing Outcomes of Transfemoral vs Transbracial or Transradial Approach in Carotid Artery Stenting (CAS)

Objectives: While Transfemoral Carotid Artery Stenting (TFCAS) remains a valid minimally invasive option for patients not suitable for Carotid Endarterectomy (CEA) or Transcarotid Artery Revascularization (TCAR), alternative access sites such as Transbrachial (TB) or Transradial (TR) are considered where anatomic factors preclude direct carotid or transfemoral access. In this study, we aimed to evaluate the outcomes of TR/TB access in comparison to TF(Transfemoral) for carotid revascularization.

Methods: All patients undergoing non-TCAR Carotid Artery Stenting(CAS) from Jan 2012-June 2021 in the Vascular Quality Initiative (VQI) Database were included. Patients were divided into two groups based on the access site for CAS: TF and TR/TB. Primary outcomes included technical failure, access site complications (hematoma, stenosis, infection, pseudoaneurysm and AV fistula) and stroke/death. Secondary outcomes included stroke, TIA, MI, death, non-home discharge, extended length of postoperative stay (LOS) (> 1 day), and composite endpoints of stroke/MI and stroke/death/MI. Univariable and multivariable logistic regression was used to assess postoperative outcomes, and results were adjusted for relevant potential confounders including age, gender, race, degree of stenosis, symptomatic status, anesthesia, comorbidities and pre-operative medications.

Results: Out of the 23,146 patients, TR/TB approach was employed in 819(3.4%) while TF was used in 23,146(96.6%). On baseline characteristics, males were more likely to undergo revascularization using TR/TB approach (69.4% vs 30.7, p=0.009) and be obese at presentation with higher BMI (29.4 vs 28.7, p=0.02). Patients undergoing TR/TB approach were more likely to be symptomatic (49.9% vs 28.6%, P< 0.001). Preoperative medication coverage was higher with TR/TB with P2Y12 inhibitor (80.3% vs 74.7%, p< 0.01), statin (83.8% vs 80.6%), and aspirin (88.3% vs 84.5%, p=0.003) (Table 1). On univariate analysis, patients with TB/TR approach experienced higher rates of adverse outcomes. However, after adjusting for potential confounders, TR/TB patients had no significant increase in risk of stroke/death [aOR 1.10(0.69-1.76),p=0.675], more than 2-fold increase in risk for in-hospital MI [aOR 2.39(1.32-4.30), p=0.004] and 2-fold increase in risk of technical failure [aOR 2.21(1.31-3.73) p=0.003]. However, there was 50% reduction in risk of access site complications [aOR 0.53(0.32-0.85), p=0.009] with TR/TB in comparison to TF. (Table 2)

Conclusions: This study confirms that although technically more challenging, Transradial or Transbrachial approach serves as a reasonable alternative with lower access site complications for CAS particularly in patients where anatomic factors preclude revascularization by TFCAS or TCAR.