Kevin O’Connor, MD
When a patient presents with a symptomatic carotid lesion, what is the optimal time to revascularize and with what procedure? Cui et al. explored this in their retrospective cohort study comparing outcomes among carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) who underwent their respective procedures urgently (0-2 days from latest symptoms), early (3-14 days), or late (15-180 days). From 2016-2019, there were 2006 urgent revascularizations (CEA, n=1112; TCAR, n=144; TFCAS, n=750), 7423 early revascularizations (CEA, n=5126; TCAR, n=929; TFCAS, n=1369), and 9214 late revascularizations (CEA, n=6060; TCAR, n=1536; TFCAS, n=1618). Analysis compared outcomes between TCAR and CEA and between TFCAS and CEA for each timeframe.
Patients who were urgently revascularized had a higher rate of perioperative death associated with TFCAS (OR, 4.3 [95% CI, 2.0–9.4] P<0.001) compared to TCAR (OR, 1.5 [95% CI, 0.3-7.2] P=0.580). Although TCAR was associated with higher risk of transient ischemic attack (TIA; TCAR OR, 5.2 [95% CI, 1.3-20.3] P=0.019 vs TFCAS OR, 0.6 [95% CI, 0.2-2.3] P=0.496) and stroke/TIA (TCAR OR, 2.6 [95% CI, 1.3-5.2] P=0.008 vs TFCAS OR, 1.1 [95% CI, 0.6-1.8] P=0.860). Early revascularization again saw an association between TFCAS and in-hospital death (OR, 2.4 [95% CI, 1.3–4.6], P=0.01) compared to TCAR (OR, 1.5 [95% CI, 0.7-3.2], P=0.278). Post-operative complications were comparable between TCAR and CEA, but there were significantly elevated rates of stroke/TIA (OR, 1.6 [95% CI, 1.1-2.3], P=0.011) and stroke/death (OR, 1.6 [95% CI, 1.1-2.4], P=0.014) for TFCAS patients.
Despite Society of Vascular Surgery guidelines for carotid revascularization within 14 days of symptomatic lesions with mild-moderate deficits, most study patients underwent late revascularization (n=9214, 49.42%). As in early revascularization, complication rates between TCAR and CEA were similar. Patients who underwent TFCAS had higher rates of stroke/TIA (OR, 1.7 [95% CI, 1.1-2.6], P=0.009) and stroke/death (OR, 1.9 [95% CI, 1.2-3.0], P=0.009), but not death (OR, 1.9 [95% CI, 0.6-5.8], P=0.260).
These retrospective data highlight the potential complications associated with TFCAS compared to CEA and TCAR, particularly in the urgent (0-2 day) timeframe. Although complication rates were similar between CEA and TCAR in the early (3-14 days) and late (15-180 days) timeframes, there were higher rates of TIA and stroke/TIA in the urgent window, and it’s not clear if this would hold true in a study with a larger number of TCAR patients. Based on the data, carotid revascularization appears safest within the early window (3-14 days) when performed with CEA or TCAR.