RS06 - Comparative Outcomes of tfCAS vs CEA vs TCAR in Standard and High-Risk Patients Since the CMS decision in October 2023 using the VQI

Objectives: In October 2023, CMS approved transfemoral carotid artery stenting (tfCAS) for standard-risk patients. Given this recent expansion, we sought to compare outcomes among tfCAS, TCAR, and CEA in standard-risk and high-risk patients.

Methods: All carotid revascularizations in the VQI following the CMS decision (October 2023–2024) were analyzed. Patients were classified as standard or high-risk per CMS criteria and stratified by symptom status. The primary outcome was perioperative stroke/death. Inverse probability of treatment weighting (IPTW) was performed to mitigate selection bias, and included demographics, comorbidities, physician volume, and operative characteristics. Time to intervention and Rankin score were added to the models for symptomatic patients to account for adherence to SVS guidelines. Outcomes were assessed with Chi-squared tests and logistic regression.

Results: Overall, 32,055 patients underwent carotid revascularization (17,083 CEA, 10,471 TCAR, and 4,501 tfCAS). Before weighting, tfCAS patients were more often symptomatic (standard-risk: 46%tfCAS vs. 25%TCAR vs. 31%CEA, p<.001; high-risk: 35% vs. 25% vs. 28%, p<.001), more frequently had a Rankin score of 4 or 5 (standard-risk:7.3% vs. 2.5% vs. 1.6%, high-risk:6.6% vs. 2.7% vs. 2.2%, p<.001) and more frequently had surgery within 48 hours (standard-risk: 21% vs. 13.7% vs. 3.1%, high-risk: 18% vs. 11% vs. 3.5%, p<.001). Standard-risk asymptomatic patients undergoing tfCAS had a higher frequency of perioperative stroke/death (1.7% vs. 0.8% vs. 0.9%, p=.05|Table 1), while there was no significant difference among symptomatic patients (3.0% vs. 1.7% vs. 1.8%, p=.07). In high-risk patients, perioperative stroke/death was higher following tfCAS (asymptomatic: 2.5% vs. 1.3% vs. 1.3%, p=.003; symptomatic: 6.4% vs. 2.4% vs. 2.4%, p<.001).
After weighting, when comparing tfCAS and TCAR to CEA in standard-risk patients, there were no differences in perioperative stroke/death overall for either tfCAS (1.4% vs. 1.3%, aOR 1.1[0.67-1.90] p=.70) or TCAR (1.1% vs. 1.3%, aOR 0.87[0.56-1.35] p=.50). This held true when stratified by symptom status (Table 2). In high-risk patients, tfCAS was associated with higher odds of perioperative stroke/death overall (2.6% vs. 1.7%, aOR 1.52[1.12-2.07] p=.01).

Conclusions: In this retrospective analysis, there were no significant differences in perioperative stroke/death when comparing carotid stenting to CEA among standard-risk patients, whereas tfCAS was associated with worse outcomes in high-risk patients. While tfCAS performed worse in unweighted analysis, after weighting, these data suggest that tfCAS may be performed safely in standard-risk patients. However, weighting in standard-risk adjusted for timing and patient selection not supported by SVS guidelines, which suggests that appropriate patient selection remains crucial to ensure acceptable outcomes.