Transcarotid artery revascularization (TCAR) has been shown to have half the rates of transient ischemic attack (TIA), stroke and death compared to transfemoral carotid artery stenting (TFCAS). Successful outcomes of TFCAS requires careful patient selection. The aim of this study was to determine the outcomes of TFCAS versus TCAR in both simple (Type I) and complex (Type II and III) aortic arches.
A retrospective cohort study was performed comparing the outcomes of patients undergoing TFCAS versus TCAR with simple and complex aortic arches using the Vascular Quality Initiative (VQI) registry from August 2011 to May 2019. The primary outcome was a composite of in-hospital TIA/stroke/death.
6108 carotid artery interventions were analyzed, including 3536 (57.9%) patients with a Type I, 2013 (33.0%) Type II, and 559 (9.2%) with a Type III aortic arch. In 3535 patients with a simple arch, 1917 underwent TFCAS and 1619 had TCAR. Mean age was 70.6 (±9.5) years and 2382 (67.4%) patients were male. The primary outcome of post-operative TIA/stroke/death was seen significantly less frequently in those undergoing TCAR compared to TFCAS in simple arches (OR, 0.63; 95% CI, 0.43-0.94; P=0.0236). Although the individual outcome of death occurred less often in TCAR (P=0.0025), there was no difference in the occurrence of in-hospital stroke (P=0.8836) or TIA (P=0.4608). On multivariable analysis, TCAR was associated with improved outcomes (P=.0062). A worse outcome was associated with increasing age (P<.001), a prior stroke (P<.0001), and increasing number of stents (P=0.0483). In 2572 patients with a complex arch, 1416 underwent TFCAS and 1156 had TCAR. Mean age was 73.0 (±9.1) years and 1655 (64.4%) were male. In complex arch anatomy, the primary outcome of in-hospital TIA/stroke/death was seen significantly less frequently in TCAR compared to TFCAS (OR, 0.49; 95% CI, 0.31 - 0.77; P=0.0022). Again noted was a significant difference in death, with better outcomes in TCAR (P=0.0133). Although the occurrence of in-hospital TIA was no different between the two approaches (P =0.6158), there were significantly fewer strokes in those treated with TCAR (P=0.0132). TCAR (P=0.0146) was associated with improved outcomes. A worse outcome was seen with advancing age (P=0.0003), prior strokes (P=0.01), and a left sided lesion (P=0.0176).
TCAR has improved outcomes of TIA/stroke/death compared to TFCAS in both simple and complex aortic arch anatomy. In simple aortic arches, there is no difference in neurological outcomes between both approaches. In complex arch anatomy TCAR has fewer strokes.

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