Transfemoral carotid artery stenting (TFCAS) was currently approved for reimbursement by the Centers for Medicare and Medicaid Services (CMS) for treatment of standard risk patients. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes, and transcarotid artery revascularization (TCAR) could be a preferable alternative in patients with complex arch anatomy. We aim to compare outcomes of TCAR versus TFCAS across all aortic arch types and degrees of arch atherosclerosis. All patients undergoing carotid artery stenting between September 2016 and October 2023 were identified in the VQI database. Patients were stratified into four groups: Group A: mild atherosclerosis and type I/II arch; Group B: mild atherosclerosis and type III arch; Group C: moderate/severe atherosclerosis and type I/II arch; and Group D: moderate/severe atherosclerosis and type III arch. The primary outcome was in-hospital composite stroke or death. Analysis of variance and χ2 tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. A total of 20,114 patients were included (Group A: 12,980; 64.53%; Group B: 1175; 5.84%; Group C: 5124; 25.47%; and Group D: 835; 4.15%) (Table I). TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94%, 69.22%; p < .001). Compared to patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group C and Group D were more likely to be female, hypertensive, smokers, and have CKD. Patients with type III arch in Group B and Group D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than one-half the risk of stroke/death and 1-year mortality compared to TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (Group A) (OR, 0.43; 95% CI, 0.31-0.61; P< .001; HR, 0.42; 95% CI, 0.32-0.57; P < .001) (Table II). Group B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared to TFCAS (OR, 0.30; 95% CI, 0.12-0.75; P = .01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR, 0.66; P = .037). Patients with advanced arch atherosclerosis and complex arch (Group D) showed the same outcome, but it was not statistically significant (OR, 0.91; P = .834). TCAR is safer than TFCAS not only in patients with advanced arch disease and complex anatomy, but also in patients with mild arch disease and simple arch configuration. Current CMS decision will likely increase stroke and death outcomes of carotid stenting nationally.Table IBaseline characteristics of patients undergoing carotid artery stenting stratified by arch type and degree of arch atherosclerosisGroup A: mild atherosclerosis and type I-II arch, No. (%)Group B: mild atherosclerosis and type III arch, No. (%)Group C: moderate to severe atherosclerosis and type I-II arch, No. (%)Group D: moderate to severe atherosclerosis and type III arch, No. (%)P value12,980 (64.53)1175 (5.84)5124 (25.47)835 (4.15)Age, years71.77 (9.10)75.00 (8.41)73.85 (8.49)76.33 (8.27)<.001Obesity (BMI >30 kg/m2)4634 (35.75)293 (24.96)1699 (33.24)193 (23.42)<.001Sex (Female)4474 (34.47)452 (38.47)2072 (40.44)374 (44.79)<.001Race (Non-White)1192 (9.19)97 (8.26)520 (10.15)64 (7.66).033Ethnicity (Hispanic or Latino)585 (4.52)37 (3.15)195 (3.81)47 (5.63).008Insurance (Medicare)8770 (67.61)903 (76.85)3681 (71.91)658 (78.90)<.001Symptomatic status Amaurosis fugax687 (5.29)61 (5.19)236 (4.61)36 (4.31).198 TIA1550 (11.94)124 (10.55)573 (11.18)101 (12.10).299 Stroke2874 (22.14)277 (23.57)1041 (20.32)211 (25.27).001Comorbidities Diabetes4957 (38.19)347 (29.53)2068 (40.38)265 (31.74)< .001 HTN11,654 (89.78)1059 (90.13)4741 (92.60)775 (93.04)<.001 CHF2090 (16.10)176 (14.98)1003 (19.59)166 (19.88)<.001 COPD2998 (23.10)315 (26.83)1588 (31.02)263 (31.50)<.001 CKD4337 (33.88)391 (33.62)1957 (39.29)306 (38.25)<.001 Dialysis140 (1.08)9 (0.77)93 (1.82)16 (1.92)<.001 ASA class IV-V3093 (24.21)300 (26.11)1468 (29.14)240 (29.02)<.001Prior procedures Prior CABG/PCI4880 (37.60)399 (33.96)2128 (41.54)303 (36.29)<.001 Prior major amputation265 (2.04)15 (1.28)113 (2.21)16 (1.92).241 Prior ipsilateral CEA/CAS1977 (15.24)139 (11.83)751 (14.66)115 (13.77).012 Prior contralateral CEA/CAS1902 (14.66)166 (14.13)903 (17.63)147 (17.60)<.001 Ipsilateral stenosis >80%5016 (48.18)396 (45.67)1953 (47.88)304 (50.00).390 Contralateral occlusion1039 (9.34)73 (7.90)532 (12.21)74 (11.23)<.001 Bovine arch1369 (10.58)121 (10.34)527 (10.33)81 (9.72).104 Elective10,797 (83.19)986 (83.91)4373 (85.34)674 (80.72)<.001Smoking history Prior smoker6129 (47.24)552 (47.02)2690 (52.55)428 (51.26)<.001 Current smoker2949 (22.73)267 (22.74)1322 (25.83)200 (23.95)<.001 General anesthesia8492 (65.44)646 (55.03)3408 (66.51)457 (54.73)<.001Preoperative medication P2Y inhibitor11,461 (88.31)1033 (87.91)4528 (88.42)745 (89.33).793 Statin11,645 (89.73)1047 (89.18)4610 (90.04)755 (90.42).746 Aspirin11,789 (90.82)1066 (90.72)4601 (89.83)746 (89.34).130 Beta-blocker6934 (53.44)600 (51.15)2926 (57.13)472 (56.53)<.001 RAAS inhibitor6917 (53.30)590 (50.21)2793 (54.53)440 (52.69).054 Anticoagulant1801 (13.88)169 (14.38)829 (16.19)130 (15.57).001ASA, American Society of Anesthesiologists; CABG, coronary artery bypass graft; CAS, carotid artery stenting; CEA, carotid endarterectomy; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention; TIA, transient ischemic attack. Open table in a new tab Table IIOutcomes of TCAR vs TFCAS stratified to aortic arch type and degree of atherosclerosisGroup ATCAR vs TFCASGroup BTCAR vs TFCASGroup CTCAR vs TFCASGroup DTCAR vs TFCASOR/HR (95% CI)P valueOR/HR (95% CI)P-valueOR/HR (95% CI)P valueOR/HR (95% CI)P valueIn-hospital outcomes Stroke/TIA0.59 (0.46-0.77)<.0010.44 (0.18-1.06).0660.69 (0.45-1.04).0741.07 (0.45-2.55).872 Stroke/death0.43 (0.31-0.61)<.0010.30 (0.12-0.75).0100.66 (0.44-0.97).0370.91 (0.39-2.16).834 Stroke/death/MI0.52 (0.38-0.72)<.0010.38 (0.17-0.85).0180.71 (0.49-1.02).0640.75 (0.36-1.58).451 Length of stay (> 1 day)0.71 (0.60-0.83)<.0010.80 (0.58-1.10).1750.89 (0.70-1.13).3230.43 (0.23-0.79).006Follow-up 1-year mortality0.42 (0.32-0.57)<.0011.06 (0.49-2.30).8760.85 (0.61-1.19).3401.22 (0.64-2.32).546CI, Confidence onterval; HR, hazard ratio; MI, myocardial infarction; OR, odds ratio; TIA, transient ischemic attack.Boldface P indicates statistical significance. Open table in a new tab
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