Recent data have shown that transcarotid artery revascularization (TCAR) with flow reversal provides a superior method of embolic protection compared with transfemoral carotid artery stenting (tfCAS) with distal embolic protection. Flow reversal or flow arrest systems with proximal endovascular balloon occlusion can also be utilized via the transfemoral approach; however, their outcomes compared with TCAR with flow reversal and tfCAS with distal embolic protection are poorly described.
We performed a retrospective review of all patients undergoing tfCAS with proximal balloon occlusion, tfCAS with distal embolic protection, and TCAR with flow reversal in the Society for Vascular Surgery Vascular Quality Initiative from March 2005 to May 2019. We assessed in-hospital outcomes using propensity-score-matched cohorts of patients, utilizing tfCAS with proximal balloon occlusion as the comparison cohort. The primary outcome was stroke or death. Secondary endpoints included the individual outcomes of stroke, death, transient ischemic attack (TIA), and myocardial infarction (MI).
Of the 24,232 patients undergoing carotid artery stenting, 561 (2.3%) were performed via tfCAS with proximal balloon occlusion, 18,126 (74%) via tfCAS with distal embolic protection, and 5,545 (22.9%) via TCAR with flow reversal. After matching, 464 pairs of patients undergoing tfCAS with proximal balloon occlusion and tfCAS with distal embolic protection were identified. There were no differences in stroke or death (proximal balloon 3.2% vs distal embolic protection 3.7%, RR 0.88 [95%CI 0.45-1.73]; P = .73), stroke (2.4% vs 2.6%, RR 0.92 [95%CI 0.42-2.00]; P = .83), death (1.1% vs 1.5%, RR 0.71 [95%CI 0.41-3.15]; P = .80), TIA (1.7% vs 1.5%, RR 1.14 [95%CI 0.41-3.15]; P = .80), or MI (0.4% vs 0.6%, RR 0.67 [95%CI 0.11-3.99]; P = .65). However, after matching 357 pairs of patients undergoing tfCAS with proximal balloon occlusion and TCAR with flow reversal, tfCAS with proximal balloon occlusion was associated with higher rates of stroke or death (3.1% vs 0.8%, RR 3.67 [95%CI 1.02-13.14]; P = .03), and a trend towards higher rates of stroke (2.5% vs 0.8%, RR 3.00 [95%CI 0.81-11.08]; P = .08) and death (0.8% vs 0.0%, P = .08), but no statistically significant differences in TIA (0.8% vs 0.8%, P > .99) or MI (0.6% vs 0.3%, RR 2.00 [95%CI 0.18-22.06], P = .56).
TfCAS with proximal balloon occlusion has similar major outcomes compared with tfCAS with distal embolic protection. However, tfCAS with proximal balloon occlusion does not offer the same degree of embolic protection compared with TCAR with flow reversal given the significantly higher risk of perioperative stroke or death.
Copyright © 2020. Published by Elsevier Inc.