Comparative Outcomes of Carotid Artery Stenting, Transcarotid Artery Revascularization, and Carotid Endarterectomy in Asymptomatic Carotid Stenosis: A Propensity-Matched Analysis.

Purpose

To compare myocardial infarction (MI), stroke, mortality, and major adverse events (MAE) after carotid artery stenting (CAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA).

Methods

Using TriNetX, adults undergoing CAS, TCAR, or CEA for asymptomatic carotid stenosis from 2015-2025 were identified using ICD-10-PCS codes. Asymptomatic status required no stroke or transient ischemic attack within 6 months before surgery. Propensity score matching was performed for CAS versus TCAR (5,558 pairs), TCAR versus CEA (9,666 pairs), and CAS versus CEA (13,707 pairs). Outcomes through 1 year were assessed using risk ratios and Kaplan-Meier analyses.

Results

At 1 year, CAS was associated with higher stroke risk than TCAR (5.16% vs 3.74%; RR 1.31; p=0.002) and CEA (4.92% vs 3.47%; RR 1.44; p<0.001), whereas TCAR and CEA were similar (3.91% vs 3.79%; p=0.52). CAS had lower mortality than TCAR (3.78% vs 7.65%; RR 0.49; p<0.001), but mortality was similar in the other comparisons. MI was lower after CAS than TCAR (2.03% vs 2.95%; RR 0.63; p<0.001), with no differences otherwise. MAE was higher after CAS than CEA (7.66% vs 6.46%; RR 1.20; p<0.001), but similar between CAS and TCAR and between TCAR and CEA.

Conclusions

Among patients selected for revascularization, CAS was associated with higher stroke risk than TCAR and CEA, lower MI and mortality than TCAR, and higher MAE than CEA. These observational findings complement randomized evidence and require cautious interpretation given residual confounding and unavailable anatomic data.