Adoption and Diffusion of Transcarotid Artery Revascularization in Contemporary Practice

Effectiveness of Transcarotid vs Transfemoral Carotid Stenting for Stroke Prevention

Importance

The effectiveness of surgical transcarotid artery revascularization (TCAR) compared with percutaneous transfemoral carotid artery stenting (TF-CAS) for stroke prevention beyond the periprocedural period is poorly quantified.

Objective

To compare the risk of stroke after TCAR vs TF-CAS.

Design, Setting, and Participants

This retrospective cohort study used data from the Vascular Implant Surveillance and Outcomes Network (VISION), a procedural registry linked to Medicare claims data that captures clinical, procedural, and outcome data on patients who underwent carotid stenting. Patients who underwent TCAR or TF-CAS between October 1, 2016, and December 31, 2019, and were captured in the VISION database were included. Data were analyzed between January and June 2024.

Exposure

Type of carotid stenting (TCAR vs TF-CAS).

Main Outcomes and Measures

The primary outcomes were any stroke, including both periprocedural and during follow-up, defined using a validated claims code list, and death. Asymptomatic and symptomatic patients were analyzed separately. Kaplan-Meier analysis was used to calculate the cumulative incidence of the outcomes, and a multivariable Cox proportional hazards model was used to determine hazard ratios (HRs).

Results

There were 5798 asymptomatic patients (mean [SD] age, 74.6 [7.7] years; 3631 male [62.6%]; 3482 underwent TCAR; 2316 underwent TF-CAS) and 4721 symptomatic patients (mean [SD] age, 74.2 [8.3] years; 2969 male [62.9%]; 2377 underwent TCAR; 2344 underwent TF-CAS) who underwent carotid stenting. Patients who underwent TCAR were older, more likely to be female, and less likely to have had a prior ipsilateral carotid revascularization procedure. Among asymptomatic patients, the Kaplan-Meier 3-year risk of stroke was lower after TCAR (5.1%; 95% CI, 3.0%-7.1%) than TF-CAS (9.2%; 95% CI, 7.7%-10.7%) (log-rank P < .001). The composite 3-year stroke or death risk after TCAR was 22.6% (95% CI, 18.8%-26.3%), compared with 31.4% (95% CI, 28.3%-34.3%) after TF-CAS (log-rank P < .001). Compared with TCAR, the adjusted HR of stroke after TF-CAS among asymptomatic patients was 1.69 (95% CI, 1.25-2.28; P < .001). Among patients with symptomatic carotid stenosis, the 3-year stroke risk was also lower for TCAR (16.6%; 95% CI, 12.1%-20.9%) than for TF-CAS (20.9%; 95% CI, 17.5%-24.1%) (log-rank P < .001). The composite 3-year stroke or death risk after TCAR was 35.9% (95% CI, 30.1%-41.2%), compared with 41.5% (95% CI, 37.6%-45.1%) after TF-CAS (log-rank P < .001). Compared with TCAR, the adjusted HR for stroke after TF-CAS among symptomatic patients was 1.42 (95% CI, 1.17-1.73; P < .001). Sensitivity analyses yielded similar results.

Conclusions and Relevance

In this comparative effectiveness study, TCAR was associated with a lower risk of stroke than TF-CAS. This finding was consistent in both asymptomatic and symptomatic patients and durable over a 3-year interval. These findings can inform procedure choices for patients considering carotid artery stenting.

Accuracy of posthospitalization stroke detection following carotid revascularization in Medicare claims

BACKGROUND

Stroke after carotid revascularization is a key effectiveness and quality metric relevant to patients, clinicians, and policymakers. To date, the accuracy of stroke rates reported from Medicare claims-based datasets for patients who underwent carotid revascularization remain unknown. The objective of this study was to validate the accuracy of using International Classification of Diseases, Tenth Revision (ICD-10) codes to detect stroke after carotid artery revascularization.

METHODS

We retrospectively reviewed all patients who underwent carotid revascularization at two institutions from January 2016 to December 2019. We used a list of ICD-10 codes to detect stroke that we derived previously and validated in two prospective cohorts with atherosclerosis. We applied the list to all patients who underwent carotid revascularization at the two institutions to identify patients with an ICD-10 code for stroke, either as the indication for the index procedure or after the procedure. We then performed a comprehensive medical record review for all stroke patients, as well as a 1:1 random sample of patients who underwent revascularization during the same time interval and did not have an ICD-10 code for stroke. Our primary outcome was the sensitivity and specificity of the ICD-10 codes to detect posthospitalization stroke (ie, after the index hospitalization) compared with a gold standard of chart review.

RESULTS

We performed a comprehensive medical record review of a cohort oversampled for stroke that included 199 patients (mean age, 73.5±7.6 years; 62.3% male; 95.0% non-Hispanic White; 61.8% symptomatic) who underwent carotid revascularization during the study interval. The majority of patients underwent carotid endarterectomy (82.4%), followed by transcarotid artery revascularization (12.1%) and transfemoral carotid artery stenting (5.5%). Twelve patients had a stroke during their index hospitalization, creating a final cohort of 187 patients eligible for assessment of posthospitalization stroke. After a median follow-up time of 453 days (interquartile range, 82-803 days), 10 asymptomatic patients and 10 symptomatic patients had a posthospitalization stroke based on chart review. Among asymptomatic patients, the sensitivity and specificity of ICD-10 codes to detect a posthospitalization stroke were 100% (95% CI, 69.2%-100.0%) and 96.8% (95% CI, 88.8%-99.6%), respectively, when considering all linked diagnosis codes. Among symptomatic patients, the sensitivity and specificity of ICD-10 codes to detect a posthospitalization stroke were 80.0% (95% CI, 44.4%-97.5%) and 94.3% (95% CI, 88.0%-97.9%), respectively, when considering all diagnosis codes.

CONCLUSIONS

Posthospitalization stroke can be measured accurately after carotid revascularization using ICD-10 codes in Medicare claims data. The reliability of the algorithm is better among asymptomatic patients than symptomatic patients.

The effect of preoperative smoking status on carotid endarterectomy outcomes in asymptomatic patients

OBJECTIVE

The current medical landscape lacks comprehensive data regarding the impact of preoperative smoking status on both short and long-term outcomes for patients undergoing carotid endarterectomy (CEA). This study seeks to elucidate the influence of smoking cessation on in-hospital and long-term outcomes in this patient population.

METHODS

Data were collected from the Vascular Quality Initiative for all asymptomatic patients who underwent CEA from 2016 to 2023. Outcomes were compared across three different smoking status groups: never smoke (NS), current smoker (CS), and quit >30 days ago. Our primary outcomes included in-hospital stroke, death, and myocardial infarction. Secondary outcomes included 1-year and 3-year death. We used inverse probability of treatment weighting to balance the following preoperative factors: age, gender, race, ethnicity, body mass index, diabetes, coronary artery disease, prior congestive heart failure, renal dysfunction, chronic obstructive pulmonary disease, hypertension, prior coronary artery bypass grafting/percutaneous coronary intervention, prior CEA/carotid artery stenting, degree of stenosis, urgency, anesthesia type, and medications.

RESULTS

The final analysis included 85,237 CEA cases with 22,343 NS (26.2%), 41,731 who quit >30 days ago (49.0%) , and 21,163 CS (24.8%). Notably, NS tended to be older and more likely to be female. In contrast, patients who quit >30 days ago were more likely to have comorbidities, including obesity, coronary artery disease, prior congestive heart failure, and CKD, as well as prior procedures. Patients who are CS were more likely to have chronic obstructive pulmonary disease and stenosis of >80%. After inverse probability of treatment weighting, we found no statistical difference for in-hospital stroke, death, myocardial infarction outcomes across the three groups. However, the long-term outcomes revealed quit >30 days ago and CS compared with NS had higher odds of 1-year death (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.5; P < .001; OR, 1.4; 95% CI, 1.2-1.6; P < .001) and 3-year death (OR, 1.5; 95% CI, 1.3-1.6; P < .001; OR, 1.5; 95% CI, 1.4-1.7; P < .001), respectively. There was no significant difference in midterm mortality outcomes between those who quit >30 days ago and CS.

CONCLUSIONS

In this large national study, we found that smoking status did not emerge as a substantial determinant of adverse short-term outcomes for asymptomatic patients undergoing CEA. However, smoking did adversely affect midterm mortality in these patients. In light of these findings, our study suggests that delaying CEA for smokers may not be warranted. It is crucial to recognize that the complex relationship between smoking and surgical outcomes requires further exploration and validation through additional prospective studies.

Using machine learning to predict outcomes following transcarotid artery revascularization

Transcarotid artery revascularization (TCAR) is a relatively new and technically challenging procedure that carries a non-negligible risk of complications. Risk prediction tools may help guide clinical decision-making but remain limited. We developed machine learning (ML) algorithms that predict 1-year outcomes following TCAR. The Vascular Quality Initiative (VQI) database was used to identify patients who underwent TCAR between 2016 and 2023. We identified 115 features from the index hospitalization (82 pre-operative [demographic/clinical], 14 intra-operative [procedural], and 19 post-operative [in-hospital course/complications]). The primary outcome was 1-year post-procedural stroke or death. The data was divided into training (70%) and test (30%) sets. Six ML models were trained using pre-operative features with tenfold cross-validation. Overall, 38,325 patients were included (mean age 73.1 [SD 9.0] years, 14,248 [37.2%] female) and 2,672 (7.0%) developed 1-year stroke or death. The best pre-operative prediction model was XGBoost, achieving an AUROC of 0.91 (95% CI 0.90-0.92). In comparison, logistic regression had an AUROC of 0.68 (95% CI 0.66-0.70). The XGBoost model maintained excellent performance at the intra- and post-operative stages, with AUROC's (95% CI's) of 0.92 (0.91-0.93) and 0.94 (0.93-0.95), respectively. Our ML algorithm has potential for important utility in guiding peri-operative risk-mitigation strategies to prevent adverse outcomes following TCAR.

An International, Expert-Based Delphi Consensus Document on Controversial Issues about TransCarotid Artery Revascularization (TCAR)

BACKGROUND

Transcarotid artery revascularization (TCAR) has emerged as an alternative therapeutic modality to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) for the management of patients with carotid artery stenosis. However, certain issues regarding the indications and contraindications of TCAR remain unanswered or unresolved. The aim of this international, expert-based Delphi consensus document was to attempt to provide some guidance on these topics.

METHODS

A 3-round Delphi consensus process was performed, including 29 experts. The aim of round 1 was to investigate the differing views and opinions of the participants. Round 2 was carried out after the results from the literature on each topic were provided to the participants. During round 3, the participants had the opportunity to finalize their vote.

RESULTS

Most participants agreed that TCAR can or can probably or possibly be performed within 14 days of a cerebrovascular event, but it is best to avoid it in the first 48 hr. It was felt that TCAR cannot or should not replace TFCAS or CEA, as each procedure has specific indications and contraindications. Symptomatic patients >80 years should probably be treated with TCAR rather than with TFCAS. TCAR can or can probably be used for the treatment of restenosis following CEA or TFCAS. Finally, there is a need for a randomized controlled trial (RCT) to provide better evidence for the unresolved issues.

CONCLUSIONS

This Delphi consensus document attempted to assist the decision-making of physicians or interventionalists or vascular surgeons involved in the management of carotid stenosis patients. Furthermore, areas requiring additional research were identified. Future studies and RCTs should provide more evidence to address the unanswered questions regarding TCAR.

Postoperative outcomes in patients with anemia undergoing carotid revascularization

BACKGROUND

Preoperative anemia is associated with worse postoperative morbidity and mortality after major vascular procedures. Limited research has examined the optimal method of carotid revascularization in patients with anemia. Therefore, we aim to compare the postoperative outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among patients with anemia.

STUDY DESIGN

This is a retrospective review of patients with anemia undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016 and 2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACE). Logistic regression models were used for multivariate analyses.

RESULTS

Our study included 40,383 CEA (59.3%), 9159 TFCAS (13.5%), and 18,555 TCAR (27.3%) cases in patients with anemia. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with a decreased 30-day mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.37-0.59; P < .001), in-hospital MACE (aOR, 0.58; 95% CI, 0.46-0.75; P < .001) compared with TFCAS. Additionally, TCAR was associated with a 20% decrease in the risk of 30-day mortality (aOR, 0.80; 95% CI, 0.65-0.98; P = .03) and a similar risk of in-hospital MACE (aOR, 0.86; 95% CI, 0.77-1.01; P = .07) compared with CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR, 2; 95% CI, 1.5-2.68; P < .001) and in-hospital MACE (aOR, 1.7; 95% CI, 1.4-2; P < .001) compared with CEA.

CONCLUSIONS

In this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS was associated with a high risk of 30-day mortality and in-hospital MACE compared with CEA and TCAR in patients with anemia. TCAR was associated with a lower risk of 30-day mortality compared with CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in patients with anemia.

Outcomes following carotid revascularization in patients with prior ipsilateral carotid artery stenting in the Vascular Quality Initiative

OBJECTIVE

The outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive.

METHODS

Using Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing.

RESULTS

We identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001).

CONCLUSIONS

In asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.

Patient decision-making in the era of transcarotid artery revascularization

OBJECTIVE

The National Coverage Determination on carotid stenting by Medicare in October 2023 stipulates that patients participate in a shared decision-making (SDM) conversation with their proceduralist before an intervention. However, to date, there is no validated SDM tool that incorporates transcarotid artery revascularization (TCAR) into its decision platform. Our objective was to elicit patient and surgeon experiences and preferences through a qualitative approach to better inform the SDM process surrounding carotid revascularization.

METHODS

We performed longitudinal perioperative semistructured interviews of 20 participants using purposive maximum variation sampling, a qualitative technique designed for identification and selection of information-rich cases, to define domains important to participants undergoing carotid endarterectomy or TCAR and impressions of SDM. We also performed interviews with nine vascular surgeons to elicit their input on the SDM process surrounding carotid revascularization. Interview data were coded and analyzed using inductive content analysis coding.

RESULTS

We identified three important domains that contribute to the participants' ultimate decision on which procedure to choose: their individual values, their understanding of the disease and each procedure, and how they prefer to make medical decisions. Participant values included themes such as success rates, "wanting to feel better," and the proceduralist's experience. Participants varied in their desired degree of understanding of carotid disease, but all individuals wished to discuss each option with their proceduralist. Participants' desired medical decision-making style varied on a spectrum from complete autonomy to wanting the proceduralist to make the decision for them. Participants who preferred carotid endarterectomy felt outcomes were superior to TCAR and often expressed a desire to eliminate the carotid plaque. Those selecting TCAR felt it was a newer, less invasive option with the shortest procedural and recovery times. Surgeons frequently noted patient factors such as age and anatomy, as well as the availability of long-term data, as reasons to preferentially select one procedure. For most participants, their surgeon was viewed as the most important source of information surrounding their disease and procedure.

CONCLUSIONS

SDM surrounding carotid revascularization is nuanced and marked by variation in patient preferences surrounding autonomy when choosing treatment. Given the mandate by Medicare to participate in a SDM interaction before carotid stenting, this analysis offers critical insights that can help to guide an efficient and effective dialog between patients and providers to arrive at a shared decision surrounding therapeutic intervention for patients with carotid disease.

Appropriateness of care: Asymptomatic carotid stenosis including transcarotid artery revascularization

Carotid artery stenosis is one of the most common diagnoses treated by vascular specialists in the United States. The optimal management of carotid stenosis remains controversial, however, with notable variation surrounding diagnostic imaging modalities, longitudinal surveillance, medical therapies, and procedural interventions. Data from high-quality randomized controlled trials and observational studies form the foundation for current management paradigms and societal guidelines that inform clinical practice. Presently, a diagnosis of carotid disease is most often established with duplex ultrasound and supplemental cross-sectional imaging using computed tomography or magnetic resonance angiography as needed to provide additional anatomic information. All patients with documented occlusive disease should receive goal-directed medical therapy with antiplatelet agents and a lipid-reduction strategy, most commonly with a statin. Those with severe carotid stenosis and an acceptable life expectancy may be considered for carotid artery revascularization. The proceduralist should optimally consider a shared decision-making approach in which the tradeoffs of revascularization can be carefully considered with the patient to optimize informed therapeutic decision making. In current practice, three distinct procedure options exist to treat carotid artery stenosis, including carotid endarterectomy, transfemoral carotid artery stenting, and transcarotid artery revascularization. It should be noted that each procedure, although often used interchangeably in most clinical settings, carry technical nuances and outcome disparities. In this review, each of these topics are explored and various approaches are outlined surrounding the appropriate use of treatments for patients with asymptomatic carotid artery stenosis.

Next-generation transcarotid artery revascularization: TransCarotid flOw Reversal Cerebral Protection And CGUARD MicroNET-Covered Embolic Prevention Stent System To Reduce Strokes - TOPGUARD Study

BACKGROUND

Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated.

METHODS

We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism.

RESULTS

One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler.

CONCLUSIONS

Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).

Thrombectomy and stenting of pseudoaneurysm from transcarotid artery revascularization

Background

Transcarotid artery revascularization (TCAR) is becoming an increasingly popular treatment of carotid stenosis. Despite this rapid adoption, little in the literature describes the associated complications of this procedure.

Case Description

We report a case of a left M1 large-vessel occlusion following treatment of symptomatic, high-grade carotid stenosis with a TCAR procedure approximately three weeks earlier. The initial angiography demonstrated a pseudoaneurysm in the left common carotid artery at the site of TCAR access with a distal clot in the carotid stent. The clot within the stent was aspirated, and a mechanical thrombectomy was performed with a combination of a stent-retriever and aspiration catheter for thrombolysis in cerebral infarction 2B revascularization.

Conclusion

The TCAR procedure offers a novel method for revascularization of carotid lesions; it does include its complications. While generally safe, access site complications such as pseudoaneurysms can always occur. Knowledge of this risk allows for appropriate surveillance and management should it occur.

Decision aids for patients with carotid stenosis

BACKGROUND

Shared decision-making tools have been underused by clinicians in real-world practice. Changes to the National Coverage Determination by Medicare for carotid stenting greatly expand the coverage for patients, but simultaneously require a shared decision-making interaction that involves the use of a validated tool. Accordingly, our objective was to evaluate the currently available decision aids for carotid stenosis.

METHODS

We conducted a review of the literature for published work on decision aids for the treatment of carotid disease.

RESULTS

Four publications met inclusion criteria. We found the format of the decision aid impacted patient comprehension and decision making, although patient characteristics also played a role in the therapeutic decisions made. Notably, none of the available decision aids included the widely adopted transcarotid artery revascularization as an option.

CONCLUSIONS

Further work is needed in the development of a widespread validated decision aid instrument for patients with carotid stenosis.

Carotid artery revascularization using second generation stents versus surgery: a meta-analysis of clinical outcomes

INTRODUCTION

Meta-analyses and emerging randomized data indicate that second-generation ('mesh') carotid stents (SGS) may improve outcomes versus conventional (single-layer) stents but clinically-relevant differences in individual SGS-type performance have been identified. No comparisons exist for SGS versus carotid endarterectomy (CEA).

EVIDENCE ACQUISITION

Thirty-day death (D), stroke (S), myocardial infarction (M), and 12-month ipsilateral stroke and restenosis in SGS studies were meta-analyzed (random effect model) against CEA outcomes. Eligible studies were identified through PubMed/EMBASE/COCHRANE. Forest plots were formed for absolute adverse evet risk in individual studies and for relative outcomes with each SGS deign versus contemporary CEA outcomes as reference. Meta-regression was performed to identify potential modifiers of treatment modality effect.

EVIDENCE SYNTHESIS

Data were extracted from 103,642 patients in 25 studies (14 SGS-treated, 41% symptomatic; nine randomized controlled trial (RCT)-CEA-treated, 37% symptomatic; and two Vascular Quality Initiative (VQI)-CEA-treated, 23% symptomatic). Casper/Roadsaver and CGuard significantly reduced DSM versus RCT-CEA (-2.70% and -2.95%, P<0.001 for both) and versus VQI-CEA (-1.11% and -1.36%, P<0.001 for both). Gore stent 30-day DSM was similar to RCT-CEA (P=0.581) but increased against VQI-CEA (+2.38%, P=0.033). At 12 months, Casper/Roadsaver ipsilateral stroke rate was lower than RCT-CEA (-0.75%, P=0.026) and similar to VQI-CEA (P=0.584). Restenosis with Casper/Roadsaver was +4.18% vs. RCT-CEA and +4.83% vs. VQI-CEA (P=0.005, P<0.001). CGuard 12-month ipsilateral stroke rate was similar to VQI-CEA (P=0.850) and reduced versus RCT-CEA (-0.63%, P=0.030); restenosis was reduced respectively by -0.26% and -0.63% (P=0.033, P<0.001). Twelve-month Gore stent outcomes were overall inferior to surgery.

CONCLUSIONS

Meta-analytic integration of available clinical data indicates: 1) reduction in stroke but increased restenosis rate with Casper/Roadsaver, and 2) reduction in both stroke and restenosis with CGuard MicroNET-covered stent against contemporary CEA outcomes at 30 days and 12 months used as a reference. This may inform clinical practice in anticipation of large-scale randomized trials powered for low clinical event rates (PROSPERO-CRD42022339789).