Comparative outcomes of transfemoral carotid artery stenting versus carotid endarterectomy versus transcarotid artery revascularization in standard- and high-risk patients since the CMS decision in October 2023 using the VQI.

Abstract

In October 2023, Centers for Medicare & Medicaid Services (CMS) approved transfemoral carotid artery stenting (tfCAS) for standard-risk patients. Thus, we sought to compare outcomes among tfCAS, transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) in standard-risk and high-risk patients. All carotid revascularization procedures in the Vascular Quality Initiative after the CMS decision (October 2023-March 2025) were analyzed. Patients were classified as standard-risk or high-risk per CMS criteria and stratified by symptom status. The primary outcome was perioperative stroke/death. Inverse probability of treatment weighting was performed to mitigate selection bias in high-risk patients and included demographics, comorbidities, physician volume, and operative characteristics. Inverse probability of treatment weighting was also applied to symptomatic standard-risk patients to account for the large proportion of tfCAS cases performed outside of Society for Vascular Surgery guidelines. Overall, 57,843 patients underwent revascularization (9123 tfCAS, 21,814 TCAR, and 26,906 CEA). Before weighting, tfCAS patients were more often symptomatic (standard-risk: tfCAS: 45% vs TCAR: 25% vs CEA: 31%, P < .01; high-risk: 35% vs 24% vs 28%, P < .01), more frequently had a modified Rankin score of 4 or 5 (standard-risk: 7.7% vs 2.4% vs 1.7%; high-risk: 6.6% vs 2.6% vs 2.4%, P < .01), and more frequently underwent urgent or emergent surgery (standard-risk: 33% vs 11% vs 16%, high-risk: 28% vs 12% vs 17%, P < .01). Standard-risk asymptomatic patients undergoing tfCAS had the highest rates of perioperative stroke/death (1.6% vs 1.2% vs 1.0%, P = .01), as did symptomatic patients (2.9% vs 1.9% vs 1.7%, P = .01). tfCAS was associated with higher overall odds of stroke/death compared with CEA (odds ratio [OR]: 1.89 [1.43, 2.48], P < .01) and TCAR (OR: 1.59 [1.15, 2.18], P < .01). Compared with CEA, tfCAS was associated with higher odds of stroke/death in both asymptomatic (OR: 1.71 [1.12, 2.55], P = .01) and symptomatic patients (adjusted OR [aOR]: 1.78 [1.21, 2.56], P < .01). After weighting, there were no significant differences in perioperative stroke/death overall for either tfCAS or TCAR compared with CEA in standard-risk symptomatic patients. In high-risk patients, TCAR was associated with lower odds of perioperative stroke/death overall compared with CEA (1.5% vs 2.1%, aOR: 0.75 [0.59, 0.94], P = .01), whereas tfCAS had higher odds of stroke/death compared with TCAR (1.5% vs 2.4%, aOR: 1.57 [1.25, 1.98], P < .01). In this retrospective analysis, there were higher odds of perioperative stroke/death when comparing tfCAS with CEA overall and among asymptomatic and symptomatic standard-risk patients, as well as overall compared with TCAR. In high-risk patients, TCAR performed better with lower odds of stroke/death compared with both CEA and tfCAS.