Transcarotid Artery Stenting Using Flow Reversal for Non-Atherosclerotic Carotid Artery Disease

OBJECTIVE: We evaluated the use of transcarotid artery revascularization (TCAR) in non-atherosclerotic carotid disease and compared outcomes with transfemoral carotid artery stenting (TFCAS). METHODS: The Vascular Quality Initiative registry was queried for all TCAR and TFCAS procedures performed from 2017-2024. Patients with lesion types categorized as atherosclerosis or restenosis were excluded. The study cohort included dissection, trauma, fibromuscular dysplasia (FMD), and other non-atherosclerotic etiologies. Primary outcomes included major adverse events, including stroke, death, and composite endpoints. Propensity score matching was performed to adjust for baseline differences. RESULTS: A total of 541 TCAR and 2,348 TFCAS patients met inclusion criteria. TCAR was associated with lower contrast usage and fluoroscopy time across all lesion types. In unadjusted analyses, stroke or death rates were higher with TFCAS than TCAR for dissection (7.1% vs 1.9%, p=0.006), other lesions (8.7% vs 2.1%, p<0.001), and symptomatic (8.1% vs 2.2%, p=0.001) and asymptomatic patients (6.4% vs 1.6%, p<0.001). After propensity matching (527 pairs), TCAR was associated with significantly lower rates of stroke (4.4% vs 1.7%, p=0.0118), death (4.4% vs 0.4%, p<0.001), stroke or death (7.6% vs 1.9%, p<0.001), and stroke, death, or MI (8.0% vs 2.7%, p<0.001) compared with TFCAS (TFCAS vs TCAR, respectively). CONCLUSIONS: This study supports consideration of TCAR for non-atherosclerotic carotid pathology when carotid stenting is indicated and suggests that TCAR may offer important advantages over TFCAS, particularly in reducing the risk of perioperative stroke or death.