Transcarotid Artery Revascularization Versus Carotid Endarterectomy With and Without High-Risk Criteria: A National Target Trial.
Academic Article
Overview
abstract
OBJECTIVE: We sought to evaluate outcomes associated with transcarotid artery revascularization with flow reversal(TCAR) versus carotid endarterectomy(CEA) for carotid artery stenosis(CAS), emulating a randomized controlled trial. SUMMARY BACKGROUND DATA: The introduction of TCAR has revolutionized management of CAS. While this approach has been demonstrated to yield reduced morbidity relative to transfemoral carotid artery stenting, a comparison of outcomes with gold-standard CEA remains lacking. METHODS: We identified all records entailing CEA or TCAR for CAS within the 2021-2022 Nationwide Readmissions Database. We conducted a target trial emulation using doubly robust inverse probability-weighted regression analysis to evaluate the adjusted hazard of 90-day composite morbidity, comprised of in-hospital stroke, myocardial infarction, or death. Patients were further stratified as high- or low-risk based on Centers for Medicare and Medicaid Services(CMS) criteria. RESULTS: We identified 113,994 patients who received CEA, and 12,613 TCAR. The adjusted risk of composite morbidity over 90 days following revascularization was 4.1% (CI 3.6-4.6%) following TCAR compared with 4.1% (CI 4.0-4.3%) after CEA. The average treatment effect of TCAR was not found to be significant. Target trial emulation revealed TCAR to confer similar hazard of 90-day composite morbidity as CEA among low-risk patients (HR 0.85, CI 0.72-1.01), but reduced hazard of myocardial infarction among high-risk patients (HR 0.76, CI 0.58-0.98). CONCLUSIONS: Upon target trial emulation, receipt of TCAR was associated with comparable morbidity over 90 days following revascularization, relative to CEA. Altogether, our data support recent CMS approval of TCAR, and encourage broadened utilization among both standard and high-risk patients.
