versus Transfemoral Carotid Artery Stenting for Treatment of Carotid Artery Stenosis Patric Liang MD Marc L Schermerhorn MD Jens EldrupJorgensen MD Jack L Cronenwett MD Brian W Nolan MD Vikram S Kashyap MD ID: 775396
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Transcarotid Artery Revascularization versus Transfemoral Carotid Artery Stenting for Treatment of Carotid Artery Stenosis
Patric Liang, MD; Marc L. Schermerhorn, MD; Jens Eldrup-Jorgensen, MD;
Jack L. Cronenwett, MD; Brian W. Nolan, MD; Vikram S. Kashyap, MD; Grace J. Wang, MD, MSCE; MD; Raghu L. Motaganahalli, MD; Mahmoud B. Malas, MD, MHS
Slide2Disclosures
MS
is a consultant for Silk Road Medical, Medtronic,
Endologix
, Cook, and Abbott
VK
is a National Co-PI for ROADSTERII.
RM
is a consultant and proctor for Silk Road Medical.
MM
is a site PI for ROADSTERI and ROADSTERII, and National PI for ROADSTERI long term follow-up study.
PL
,
JJ
,
JC
,
BN
, and
GW
have no disclosures.
Slide3Pivotal randomized trails have found higher periprocedural stroke risk for transfemoral carotid stenting (tfCAS) compared to endarterectomy
Transcarotid revascularization (TCAR) with flow reversal was developed to eliminate the high embolic-risk maneuvers inherent to tfCAS
Preliminary analysis from the VQI TCAR Surveillance Project showed lower neurological complications based on embolic events manifested as transient ischemic attackLimited to small sample size
Background
Objective
Methods
Results
Conclusion
Slide4Background
Objective
MethodsResultsConclusion
Year
% CAS performed via TCAR20165.9%201726.0%201846.5%2019 (April)56.3%
TCAR and tfCAS Trend in the VQI
Slide5Examine perioperative and one-year outcomes of patients undergoing
TCAR and tfCAS in the VQI TCAR Surveillance Project.
Background
Objective
Methods
Results
Conclusion
Slide6Background
Objective
MethodsResultsConclusion
Prospective registry, clinical trial (NCT02850588)
Study Period: September 2016 to April 2019
Inclusion
-
TCAR and
tfCAS
procedures for atherosclerotic or intimal hyperplasic disease
Exclusion
–
Concomitant planned intracranial procedures
Unknown presenting symptom status or presenting symptom severity
Primary Outcome
In-hospital, 30-day, and 1-year stroke/death
Secondary Outcomes
Stroke, death, myocardial infarction, bleeding complication, procedure time, fluoroscopy time, contrast volume, CMS discharge criteria (failed discharge home or LOS >2 days)
Propensity Score Matched Analysis
Slide7Background
Objective
MethodsResultsConclusion
Baseline Characteristics
tfCASN = 6640TCARN = 5251P-valueAge, y70 + 9.773 + 9.4<.001Symptomatic TIA Stroke65%23%43%49%20%30%<.001Prior CEA/CAS21%17%<.001Risk Factors Coronary Artery Disease Congestive Heart Failure Hypertension Chronic Kidney Disease (GFR<60)44%16%89%35%51%19%91%40%<.001.002<.001<.001CMS High-Risk CEA Criteria Anatomic Medical44%37%50%57%<.001<.001
Slide8Background
Objective
MethodsResultsConclusion
Baseline Characteristics
tfCASN = 6640TCARN = 5251P-valuePreoperative Medications Aspirin P2Y12 inhibitors Statin87%77%83%90%87%89%<.001<.001<.001Physician Carotid Stent Volume Low (0-3) Medium (4-24) High (25-87)24%56%20%26%56%18%.01Center Carotid Stent Volume Low (0-14) Medium (15-66) High (25-87)18%59%23%25%59%16%<.001
Slide9Background
Objective
MethodsResultsConclusion
Propensity Score Matching
3286 Matched Pairs
Slide10Background
Objective
MethodsResultsConclusion
Technical Outcomes
tfCASN = 3286TCARN = 3286P-valueTechnical Failure1.2%0.5%<.001 Unable to access CCA0.4%0.1%.003 Unable to cross carotid lesion0.6%0.2%.002 Unable to deploy stent0.2%0.2%.59Embolic device placement failure5.8%0.3%<.001 Unable to insert device1.0%0.1%<.001
Slide11Background
Objective
MethodsResultsConclusion
In-Hospital Outcomes
tfCASN = 3286TCARN = 3286P-valueStroke/Death3.1%1.6%<.001 Stroke2.4%1.3%.001 Death1.0%0.4%.008Myocardial Infarction0.3%0.2%.47Bleeding Complication0.8%1.3%.04
Slide12Background
Objective
MethodsResultsConclusion
In-Hospital Outcomes
tfCASN = 3286TCARN = 3286P-valueProcedural Time (mins)72 + 4174 + 30.02Fluoroscopy Time (mins)19 + 136.1 + 8.6<.001Contrast Volume94 + 5737 + 27<.001Failed CMS Discharge Criteria Length of stay >2 days Failed Discharge Home23%19%13%16%14%7.3%<.001<.001<.001
Slide13Background
Objective
MethodsResultsConclusion
Symptomatic N = 3658Asymptomatic N=2876tfCASN = 1829TCARN = 1829P-valuetfCASN = 1438TCARN = 1438P-valueStroke/Death4.2%2.1%<.0011.5%1.0%.32 Stroke3.1%2.0%.0351.3%0.7%.13 Death1.5%0.5%.0020.2%0.4%.32Myocardial Infarction0.3%0.1%.060.3%0.3%.74Bleeding Complication0.7%1.3%.130.5%1.3%.02Failed CMS Discharge Criteria Length of stay >2 days Failed Discharge Home32%26%21%22%18%11%<.001<.001<.0019.9%9.2%2.8%10%9.0%2.0%.80.85.18
Slide14Background
Objective
MethodsResultsConclusion
Protamine Use in TCAR
No ProtamineN = 944ProtamineN = 944P-valueStroke/Death2.2%1.6%.32 Stroke2.0%1.1%.09 Death0.7%0.5%.56Myocardial Infarction0.2%0.3%.65Any Bleeding Complication8.3%2.8%<.001 Interventional treatment3.6%1.0%<.001 Blood Transfusion3.9%1.2%<.001
Slide15Background
Objective
MethodsResultsConclusion
30-day Outcomes
tfCAS
N = 3286
TCAR
N = 3286
P-value
Stroke/Death
3.7%
1.9%
<.001
Stroke
2.5%
1.3%
<.001
Death
1.5%
0.8%
.007
Slide16Background
Objective
MethodsResultsConclusion
TCAR
tfCAS
Number at Risk
Transfemoral
Transcarotid
Freedom From Stroke/Death: 1-Year
94.9% vs 90.5%
HR 0.55, 95%CI 0.46-0.66, P < .001
Slide17Background
Objective
MethodsResultsConclusion
TCAR is associated with lower rates of stroke and
death
compared to tfCAS
The stroke/death differences persistent up to one-year
Benefits from TCAR are particularly compelling for symptomatic carotid disease
Protamine use in TCAR results in significantly decreased bleeding complications without differences in thrombotic complications
TCAR with flow reversal should be preferred carotid stenting technique
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