Transcarotid Artery Revascularization versus Carotid Artery Stenting for Asymptomatic Carotid Stenosis

Abstract

Background: The CREST-2 trial demonstrated superiority of carotid artery stenting (CAS) over intensive medical management for asymptomatic carotid stenosis, but it did not evaluate transcarotid artery revascularization (TCAR). Herein, we compared ischemic stroke outcomes between TCAR and CAS among asymptomatic carotid stenosis patients in contemporary real-world practice. Methods: We identified adults with asymptomatic carotid stenosis undergoing TCAR vs. CAS using the 2016–2024 TriNetX database, which is a multicenter federated database of electronic health records. Propensity score matching was performed for demographics, laboratory values, risk factors, comorbidities, and medications. The primary outcome was ischemic stroke within 4 years. Results: Among 7,303 identified patients, 2,207 patients remained in each group after matching. TCAR did not demonstrate a significantly different stroke risk compared to CAS (hazard ratio 0.68 [95%CI 0.44-1.06]). The absolute risk difference was numerically but non-significantly lower for TCAR patients throughout the follow-up period, progressively widening over time: 0.35% at 6 months (0.61% vs 0.96%, p=0.18) to 1.55% at 4 years (3.26% vs 4.81%, p=0.086). Conclusion: TCAR did not significantly lower stroke risk compared to CAS for asymptomatic carotid stenosis. While non-significant trends towards lower stroke risk were observed for TCAR, the widening of absolute risk differences over time suggests residual confounding rather than potential procedural benefit.