Carotid endarterectomy is associated with lower rates of reintervention compared to carotid stenting

Objectives Perioperative outcomes for carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) have been well studied. Less is known about the durability and reintervention rates of each, particularly in the era of transcarotid artery revascularization (TCAR). We sought to compare real-world rates of ipsilateral reintervention, stroke, and death in patients undergoing CEA, TFCAS, and TCAR. Methods The Vascular Quality Initiative (VQI) was matched to Medicare claims via the Vascular Implant Surveillance and Implantation Network (VISION) database to identify patients who had primary carotid revascularization from December 2016 to December 2019 in a n observational cohort study. The primary outcome was ipsilateral reintervention; secondary outcomes included stroke and mortality. After 1:1 greedy matching using propensity scores, patients who underwent CEA and carotid artery stenting (CAS) via either transcarotid or transfemoral approach were compared using time-dependent Cox regression models. A separate propensity matched analysis was then performed to compare TFCAS and TCAR. Kaplan-Meier curves were compared using log rank tests. Results After propensity matching (N=27,944 patients), we compared 4705 patients in each group. Risk of re-intervention was increased within 6 months for CAS (HR: 1.97; 95% CI: 1.11-3.50; p<0.05), but not beyond 6 months (HR: 1.08; 95% CI: 0.62-1.89; p=0.79). The incidence of stroke prior to discharge was increased in patients undergoing CAS (5.4% v. 1.0%; p<0.0001) and mortality hazard with CAS was increased both within 6 months (HR:1.69; 95% CI: 1.38- 2.07; p<0.0001) and beyond 6 months (HR: 1.52; 95% CI: 1.27-1.81; p<0.0001). When comparing TFCAS and TCAR (n=2115 per group), there was a significantly increased risk of re- intervention for TFCAS beyond 6 months (HR: 2.31, 95% CI: 1.05-5.11, p <0.05). Conclusions CEA portends a lower risk of reintervention than CAS, particularly within the first 6 months after revascularization. On subgroup analysis of stenting modalities, TCAR had a lower hazard of longer-term reintervention compared to TFCAS.