Three-year risk of stroke after transcarotid artery revascularization versus carotid endarterectomy among Medicare beneficiaries

Jesse A Columbo; Pablo Martinez-Camblor; David H Stone; Philip P Goodney; Mark A Creager; Todd A MacKenzie; Haobin Chen; A James O'Malley; Caitlin W Hicks

doi:10.1016/j.jvs.2025.06.052

Three-year risk of stroke after transcarotid artery revascularization versus carotid endarterectomy among Medicare beneficiaries

J Vasc Surg. 2025 Jul 11:S0741-5214(25)01401-6. doi: 10.1016/j.jvs.2025.06.052. Online ahead of print.

Authors

Jesse A Columbo¹, Pablo Martinez-Camblor², David H Stone³, Philip P Goodney³, Mark A Creager⁴, Todd A MacKenzie⁵, Haobin Chen⁶, A James O'Malley², Caitlin W Hicks⁷

Affiliations

¹ Geisel School of Medicine at Dartmouth, Hanover NH; Section of Vascular Surgery, Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Lebanon NH. Electronic address: Jesse.a.columbo@dartmouth.edu.
² Department of Biomedical Data Science, Dartmouth College, Lebanon NH; Department of Anesthesia, Dartmouth Hitchcock Medical Center, Lebanon NH.
³ Geisel School of Medicine at Dartmouth, Hanover NH; Section of Vascular Surgery, Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Lebanon NH.
⁴ Geisel School of Medicine at Dartmouth, Hanover NH; Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth Hitchcock Medical Center.
⁵ Department of Biomedical Data Science, Dartmouth College, Lebanon NH; Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon NH.
⁶ Department of Biomedical Data Science, Dartmouth College, Lebanon NH.
⁷ Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.

PMID: 40653125
DOI: 10.1016/j.jvs.2025.06.052

Abstract

Background: Transcarotid artery revascularization (TCAR) has seen widespread adoption in contemporary practice. However, the risk of stroke after TCAR versus carotid endarterectomy (CEA) beyond the perioperative period remains poorly defined. Our objective was to compare the 3-year risk of stroke after TCAR versus CEA.

Methods: We performed a retrospective cohort study using data from the Vascular Implant Surveillance and Outcomes Network (VISION), a procedural registry linked to Medicare claims data that captures clinical, procedural, and outcomes data on patients who underwent carotid revascularization. We studied patients who underwent TCAR or CEA and were part of the VISION database between 10/1/2016 (start of TCAR surveillance registry) and 12/31/2019 (end of linked Medicare claims availability). The primary exposure was surgery type (TCAR or CEA). The primary outcome was stroke, defined using a validated claims code list, and death. Asymptomatic and symptomatic patients were analyzed separately. We used Kaplan-Meier analysis and Cox-regression for risk adjustment. We used competing-risk and propensity score methods for sensitivity analyses.

Results: There were 19,141 asymptomatic (TCAR:3,482, CEA:15,659) and 12,343 symptomatic (TCAR:2,377, CEA:9,966) patients who underwent carotid surgery. Patients who underwent TCAR were older, more likely to be female, and more likely to be anatomic high-risk. Among asymptomatic patients, the 3-year risk of stroke was similar after TCAR (5.1% [95%CI:3.0-7.1%]) and CEA (4.9% [95%CI:4.4-5.4%], log-rank p=0.93). The composite 3-year risk of stroke or death was 22.6% (95%CI:18.8-26.3%) after TCAR and 20.0% (95%CI:18.8-21.2%) after CEA (log-rank p<0.001). Compared to CEA, the adjusted HR of stroke after TCAR among asymptomatic patients was 1.10 (95%CI:0.82-1.49). Among patients with symptomatic carotid stenosis, the 3-year risk of stroke was also similar between TCAR (16.6% [95%CI:12.1-20.9%]) and CEA (13.6% [95%CI:12.5-14.7%], log-rank p=0.17). The composite 3-year risk of stroke or death risk was 35.9% (95%CI:30.1-41.2%) after TCAR and 30.0% (95%CI:28.3-31.7%) after CEA (log-rank p<0.001). Compared to CEA, the adjusted HR for stroke after TCAR among symptomatic patients was 1.00 (95%CI: 0.75-1.33).

Conclusions: In this comparative-effectiveness study, TCAR had a similar risk of stroke to CEA. This was durable over 3 years of follow-up and was consistent among asymptomatic and symptomatic patients. These results can inform procedure choices for both patients and providers alike when considering carotid surgery and help to inform requisite shared decision making prior to intervention.

Keywords: CEA; Carotid; TCAR; carotid stent; comparative effectiveness research; health services research; stroke; transcarotid.