IYSC03 - One Year Outcomes of TransCarotid Artery Revascularization versus Carotid Endarterectomy in Medicare Database

Objectives: Carotid Endarterectomy (CEA) has played a major part in reducing stroke in patients with significant carotid artery stenosis. Transcarotid artery revascularization (TCAR) was introduced as a minimally invasive hybrid procedure to treat patients who are considered anatomically and/or medically high risk for CEA. Prior studies reported no differences in perioperative stroke/death between TCAR and CEA. However, data regarding one-year outcomes of TCAR versus CEA are scarce and all prior studies had only about 50% follow up at one year. Herein, we will report perioperative as well as one-year outcomes of TCAR versus CEA in the Vascular Quality Initiative (VQI) database linked to Medicare claims.

Methods: Patients undergoing TCAR and CEA from September 2016 to December 2018 were identified in the VQI- Vascular Implant Surveillance and Interventional Outcomes Network database. Patients with trauma, dissection, tandem, and multiple lesions treated were excluded from the analysis. Primary endpoint was one-year combined stroke or death. Secondary endpoints included perioperative stroke, death, and combined stroke or death as well as one-year stroke and death. One-to-one propensity-score-matched analysis without replacement was performed for TCAR vs. CEA based on patients’ demographics, comorbidities, preoperative medications, insurance, and physician volume.

Results: A total of 30,033 patients underwent CEA and 3,573 underwent TCAR during the study period. TCAR patients were older and with significant more comorbidities. After PSM, the two cohorts were well-matched in terms of demographics and comorbidities (Table I). There was no difference in perioperative stroke or death between TCAR and CEA before (OR: 1.1, 95%CI (0.9-1.3), P=0.357) or after matching (RR: 0.8, 95%CI (0.6-1.02), P=0.073). Before matching, TCAR was associated with higher risk of one-year stroke/death (13.2% vs 10.8%, HR: 1.2, 95%CI (1.1-1.4), P=0.001) and death (7.9% vs 5.7%, HR: 1.4, 95%CI (1.2-1.7), P< 0.001). Among 3,157 matched pairs of TCAR vs. CEA, there were no differences in one-year stroke (6.6% vs 7.6%, HR: 0.86, 95%CI (0.7-1.05), P=0.139), death (7.7% vs 8.05%, HR: 1.01, 95%CI (0.8-1.2), P=0.9) and stroke or death (12.8% vs 14.2%, HR:0.9, 95%CI (0.78-1.06), P=0.227). One-year outcomes persisted after stratifying with respect to symptomatic status (Table II).

Conclusions: In this large propensity-score matched analysis utilizing 100% Medicare matching and complete follow-up, we found no significant differences in perioperative and one-year outcomes between TCAR and CEA regardless of symptomatic status. Therefore, TCAR can be performed safely in high-risk patients not eligible for CEA. Future randomized clinical trial is needed to compare TCAR to CEA in normal risk patients.