Impact of embolic protection methods versus access types on outcomes of carotid artery stenting.

Objective: Carotid artery stenting (CAS) is commonly performed through transfemoral or transcarotid access. Neurologic protection methods utilized during the procedure include distal embolic protection (DEP) and flow reversal devices. Multiple studies demonstrated more favorable outcomes associated with transcarotid artery revascularization with flow reversal (TCAR) in comparison to transfemoral carotid artery stenting with DEP (TFCAS-DEP). However, not many studies compared TCAR with transcarotid artery stenting with DEP (TCAS-DEP) or TFCAS with flow arrest by proximal balloon occlusion (TFCAS-PBO). We aimed to compare the effect of access types and embolic protection methods on the outcomes of CAS.

Methods: All patients undergoing CAS between September 2016 and August 2024 were identified in the Vascular Quality Initiative database. Inverse probability of treatment weighting based on propensity scores was used to compare outcomes of TFCAS-DEP, TFCAS-PBO, and TCAS-DEP with TCAR. Cohorts were weighted with regards to 27 baseline variables.

Results: A total of 99,030 patients were included in our study: TCAR, 66,655 (67.3%); TFCAS-DEP, 30,723 (31.0%); TCAS-DEP, 912 (0.9%); and TFCAS-PBO, 740 (0.8%). Compared with TCAR, TFCAS-DEP had more than double the odds of in-hospital and 30-day mortality (odds ratio [OR], 2.68; 95% confidence interval [CI], 2.25-3.19; P < .001; OR, 2.39; 95% CI, 2.08-2.74; P < .001), and 62% higher odds of stroke/death (OR, 1.62; 95% CI, 1.45-1.81; P < .001). The TCAS-DEP group had double the risk of 30-day mortality (OR, 2.00; 95% CI, 1.13-3.53; P = .016) and 58% increased risk of stroke (OR, 1.58; 95% CI, 1.04-2.38; P = .031). Finally, higher odds of in-hospital and 30-day mortality (OR, 2.47; 95% CI, 1.22-5.00; P = .012; and OR, 1.85; 95% CI, 1.03-3.30; P = .038, respectively) were observed in the TFCAS-PBO group when compared with TCAR.

Conclusions: In this large, comprehensive multi-institutional study comparing carotid access types and embolic protection methods, TCAR seems to be the safest endovascular carotid revascularization procedure owing to its lower risk of postoperative stroke or death. This study confirms that avoidance of the aortic arch and flow reversal neuroprotection are both important in reducing complications following CAS.