Society for Vascular Surgery Vascular Quality Initiative Contemporary Benchmarks: Carotid Artery Stenting

Carotid artery stenting (CAS) utilization and indications have evolved substantially with the introduction of transcarotid artery revascularization (TCAR), recent regulatory expansion, and renewed attention following contemporary trial data. We sought to establish contemporary real-world benchmark outcome rates for CAS and characterize temporal trends and modality adoption within the Vascular Quality Initiative (VQI).

We analyzed all CAS procedures recorded in the VQI from 2011-2024. Contemporary benchmark analyses were restricted to procedures performed from 2021-2024, selected to reflect recent practice following the COVID-19 pandemic and the maturation of TCAR adoption, and stratified by symptomatic status and modality (TCAR vs transfemoral CAS [TFCAS]). Primary outcomes included in-hospital stroke, death, myocardial infarction (MI), and major adverse cardiovascular events (MACE). One-year ipsilateral stroke and mortality were assessed among patients with available long-term follow-up data. Temporal trends in utilization were evaluated across the full study period and in relation to regulatory milestones, outcomes were compared by operator volume and physician-level TCAR adoption patterns were examined among Physicians with an established pre-2016 TFCAS practice.

A total of 119,240 CAS procedures were identified across 821 centers and 3,991 physicians, including 78,997 performed during the 2021-2024 benchmark period. TCAR comprised 73.6% of procedures performed during 2021-2024. In-hospital stroke rates were lower with TCAR than TFCAS in both asymptomatic (0.9% vs 1.4%) and symptomatic patients (1.8% vs 2.8%), as were death (0.3% vs 0.7% asymptomatic; 0.5% vs 1.8% symptomatic) and MACE (1.5% vs 2.1% asymptomatic; 2.5% vs 4.4% symptomatic; all p<0.05). One-year ipsilateral stroke was lower after TCAR in symptomatic patients (5.6% vs 8.5%, p<0.001) but did not differ significantly in asymptomatic patients (2.8% vs 3.4%, p=0.054); one-year mortality was lower after TCAR in both strata (3.0% vs 4.5% asymptomatic; 5.0% vs 7.6% symptomatic; both p<0.001). In 2016, TCAR accounted for 7% of CAS procedures and TFCAS 93%, shifting to 76% and 24% respectively by 2023; annual TFCAS volume remained relatively stable through 2020 before increasing thereafter. Following the October 2023 CMS National Coverage Determination extending standard-risk coverage to both modalities, TCAR volume fell 11.5% (p=0.008) and then declined 0.6% per month through December 2024, while TFCAS volume rose 11.2% (p=0.026). Among 97 physicians with established pre-2016 TFCAS practice who subsequently adopted TCAR and remained active through 2022-2024, TCAR accounted for 85% of CAS volume by 2024, with lower pre-existing TFCAS volume associated with faster TCAR adoption.

In contemporary VQI practice, TCAR is associated with lower unadjusted in-hospital and one-year stroke and mortality rates compared with TFCAS regardless of symptomatic status. TCAR adoption grew rapidly from 2016 through 2023 before declining following the October 2023 CMS policy change. As CAS utilization expands in the setting of evolving policy and trial evidence, these findings provide contemporary real-world benchmarks and underscore the need for continued registry-based surveillance.