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A Murine Model of Stent Implantation in the Carotid Artery for the Study of Restenosis
Published on: May 14, 2013
Determinants of Mortality and Mid-Term Outcomes After Transcarotid Artery Revascularization and Transfemoral Carotid
Jerry Zhu1, Ajit Rao1, Kelsey Berger1
1Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Insights
Transcarotid artery revascularization (TCAR) shows a significant 3-year survival advantage over transfemoral carotid artery stenting (tfCAS), with benefits established early. Postoperative stroke is the key predictor of mortality following TCAR.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Comparative Effectiveness Research
Background:
- Transcarotid artery revascularization (TCAR) demonstrates perioperative benefits over transfemoral carotid artery stenting (tfCAS), but mid-term outcome data are limited.
- Existing research lacks comparative analysis of TCAR versus tfCAS, particularly concerning pre-operative symptoms and long-term efficacy.
- Uncertainty remains regarding the persistence of TCAR's initial stroke and death reduction benefits beyond one year.
Purpose of the Study:
- To evaluate 3-year outcomes comparing TCAR and tfCAS.
- To identify primary predictors of 30-day and 1-year mortality after TCAR.
- To provide evidence for clinicians assessing TCAR efficacy up to three years post-procedure.
Main Methods:
- Analysis of data from the Vascular Quality Initiative (2016-2022) for TCAR and tfCAS patients.
- 1:1 propensity score matching to adjust for baseline differences, followed by Kaplan-Meier survival analysis and Cox regression.
- Logistic regression and Cox regression were used to identify predictors of 30-day and 1-year mortality.
Main Results:
- TCAR patients were older with higher comorbidity rates; propensity score matching created comparable groups.
- TCAR showed a 24% reduction in 3-year mortality hazard versus tfCAS (HR=0.76), with the advantage established within 6 months.
- TCAR also demonstrated decreased 3-year hazard for stroke and for stroke or death compared to tfCAS.
Conclusions:
- TCAR offers a sustained mid-term survival advantage over tfCAS, primarily established within the first six months post-procedure.
- Postoperative complications, especially stroke, are identified as the primary independent predictors of 30-day and 1-year mortality following TCAR.
- These findings support TCAR's efficacy and highlight the critical importance of managing postoperative complications.
Objectives:
The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR.
Methods:
Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors.
Results:
A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke.
Conclusions:
Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal.Clinical ImpactThe ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.
