Outcomes of Carotid Artery Revascularization in Asymptomatic Carotid Artery Stenosis: A Stroke Center Analysis

High-grade asymptomatic carotid artery stenosis is a well-established risk factor for cerebrovascular events. While carotid endarterectomy (CEA) remains the standard of care, transfemoral carotid artery stenting (TFCAS) and transcarotid artery revascularization (TCAR) have emerged as less invasive alternatives.

This retrospective cohort study included patients with asymptomatic carotid stenosis who underwent revascularization at a stroke center between 2015 and 2024. Primary and secondary outcomes included rates of ipsilateral stroke, transient ischemic attack (TIA), myocardial infarction (MI), and death at 30 days and on mid-term follow-up. Restenosis and reintervention rates were also evaluated. In addition, the outcomes of CEA and TFCAS were compared using data from the Southeastern Vascular Study Group (SEVSG) regional database.

A total of 275 patients underwent 293 carotid artery interventions, including 158 (53.9%) CEA, 68 (23.2%) TCAR, and 67 (22.9%) TFCAS. There were no differences in baseline characteristics except for a significantly higher proportion of male patients in the TCAR group (CEA: 61.4%, TFCAS: 56.7%, TCAR: 77.9%, P = 0.02) and lower body mass index in the CEA group (CEA: 27.7 ± 4.6, TFCAS: 29.7 ± 5.6, TCAR: 29.4 ± 5.5, P < 0.01). The composite outcome of ipsilateral stroke/TIA/MI/death within 30-days following the procedure was not different among the groups (TFCAS: 3.0%, CEA: 1.9%, TCAR: 0.0%, P = 0.34), with no significant differences in death rates (CEA: 1.9%, TFCAS: 1.5%, TCAR: 0.0%, P = 0.67) or ipsilateral stroke rates (CEA: 0.0%, TFCAS: 1.5%, TCAR: 0.0%, P = 0.23). No MI or TIA events were observed. At mid-term follow-up of 1.6 ± 1.5 years, the composite outcome was also similar (CEA: 15.8%, TFCAS: 13.4%, TCAR: 25.5%, P = 0.15), with no significant differences in ipsilateral stroke rates (CEA: 1.3%, TFCAS: 4.5%, TCAR: 0.0%, P = 0.11), TIA rates (CEA: 0.0%, TFCAS: 3.0%, TCAR: 0.0%, P = 0.05), MI rates (CEA: 1.3%, TFCAS: 1.5%, TCAR: 4.4%, P = 0.3), or death rates (CEA: 13.3%, TFCAS: 6.0%, TCAR: 19.1%; P = 0.07). The TFCAS group had a significantly higher rate of restenosis (CEA: 0.0%, TFCAS: 7.5%, TCAR: 2.9%, P < 0.01) and reintervention compared to the CEA and TCAR groups (CEA: 0.0%, TFCAS: 6.0%, TCAR: 0.0%, P < 0.01). On multivariable Cox regression analysis, the use of closed-cell stents was independently associated with a higher risk of restenosis (hazard ratio 6.48, 95% confidence interval 1.14-36.76, P = 0.02). From the SEVSG regional analysis, 30-day term outcomes demonstrated no significant differences in ipsilateral stroke (CEA: 0.5%, TFCAS: 0.4%, P = 0.87), TIA (CEA: 0.2%, TFCAS: 0.0%, P = 0.49), death rates (CEA: 1.6%, TFCAS: 0.9%, P = 0.43), or composite outcomes (CEA: 2.3%, TFCAS: 1.3%, P = 0.45), while mid-term outcomes revealed higher composite rates (CEA: 7.8%, TFCAS: 11.1%, P < 0.01) and death rates in the TFCAS group (CEA: 4.2%, TFCAS: 8.2%, P < 0.01). Most deaths were of unknown causes within our regional dataset (CEA: 1.75%, TFCAS: 4.5%), followed by non-carotid-related causes (CEA: 2.4%, TFCAS: 3.6%). Restenosis rates were higher in the TFCAS group compared to the CEA group (CEA: 0.3%, TFCAS: 13.8%, P < 0.01). Reintervention rates were higher, but not significant, in the TFCAS group (CEA: 1.0%, TFCAS: 1.8%, P = 0.05).

Our stroke center's results demonstrate comparable outcomes following CEA, TFCAS, and TCAR in the asymptomatic carotid artery stenosis patient population. TFCAS was associated with higher restenosis rates in both in our cohort and the regional dataset. These findings emphasize the need for an individualized approach when considering carotid artery revascularization in this patient population.