Propensity-Score Matched Analysis of Three Years Survival of TransCarotid Artery Revascularization Versus Carotid Endarterectomy in the Vascular Quality Initiative Medicare Linked Database

Abstract

Objective: Carotid endarterectomy (CEA) remains the gold standard procedure for carotid revascularization. Transfemoral carotid artery stenting (TFCAS) was introduced as a minimally invasive alternative procedure in patients who are at high risk for surgery. However, TFCAS was associated with increased risk of stroke and death compared to CEA. Summary background data: Transcarotid artery revascularization (TCAR) has outperformed TFCAS in several prior studies and has shown similar perioperative and one-year outcomes compared to CEA. We aimed to compare the one-year and three-year outcomes of TCAR vs. CEA in the Vascular Quality Initiative (VQI)-Medicare-Linked (Vascular Implant Surveillance & Interventional Outcomes Network [VISION]) database. Methods: The VISION Database was queried for all patients undergoing CEA and TCAR between September 2016 to December 2019. The primary outcome was one-year and three-years survival. One-to-one propensity-score matching (PSM) without replacement was used to produce two well-matched cohorts. Kaplan-Meier estimates, and Cox regression were used for analyses. Exploratory analyses compared stroke rates using claims-based algorithms for comparison. Results: A total of 43,714 patients underwent CEA and 8,089 patients underwent TCAR during the study period. Patients in the TCAR cohort were older and were more likely to have severe comorbidities. PSM produced two well-matched cohorts of 7,351 pairs of TCAR and CEA. In the matched cohorts, there were no differences in one-year death (HR=1.13, 95% CI: 0.99-1.30; P=0.065). At three-years, TCAR was associated with slight increased risk of death (HR=1.16, 95% CI: 1.04-1.30; P=0.008). When stratifying by initial symptomatic presentation, the increased three-year death associated with TCAR persisted only in symptomatic patients (HR=1.33, 95% CI: 1.08-1.63; P=0.008). Exploratory analyses of post-operative stroke rates using administrative sources suggested that validated measures of claims-based stroke ascertainment are necessary. Conclusions: In this large multi-institutional PSM analysis with robust Medicare-linked follow-up for survival analysis, the rate of death at one-year was similar in TCAR and CEA regardless of symptomatic status. The slight increase in the risk of three-year death in symptomatic patients undergoing TCAR is likely confounded by more severe comorbidities despite matching. A randomized controlled trial comparing TCAR to CEA is necessary to further determine the role of TCAR in standard risk patients requiring carotid revascularization.

Modality-specific outcomes of patients undergoing carotid revascularization in the setting of recent myocardial infarction

“…33 In a follow-up study using both VQI and Medicare data, Malas et al found the rate of death at one-year was similar in TCAR and CEA regardless of symptomatic status. 34 Together, these findings may suggest that recent MI should not be a contraindication for TCAR or CEA. Additionally, given that CEA performed better than TFCAS in terms of in-hospital stroke/death and stroke/death/MI, our results suggest that designating pre-operative MI as a highrisk factor for CEA should be re-evaluated.…”