1. Transcarotid Artery Revascularization versus Transfemoral Carotid Artery Stenting for Treatment of Carotid Artery Stenosis
Patric Liang, MD; Marc L. Schermerhorn, MD; Jens Eldrup-Jorgensen, MD; Jack L. Cronenwett, MD; Brian W. Nolan, MD; Vikram S. Kashyap, MD; Grace J. Wang, MD, MSCE; MD; Raghu L. Motaganahalli, MD; Mahmoud B. Malas, MD, MHS

2. Disclosures
MS is a consultant for Silk Road Medical, Medtronic, Endologix, Cook, and Abbott
VK is a National Co-PI for ROADSTERII.
RM is a consultant and proctor for Silk Road Medical.
MM is a site PI for ROADSTERI and ROADSTERII, and National PI for ROADSTERI long term follow-up study.
PL, JJ, JC, BN, and GW have no disclosures.

3. Limited to small sample size
Background
Objective
Methods
Results
Conclusion
Pivotal randomized trails have found higher periprocedural stroke risk for transfemoral carotid stenting (tfCAS) compared to endarterectomy
Transcarotid revascularization (TCAR) with flow reversal was developed to eliminate the high embolic-risk maneuvers inherent to tfCAS
Preliminary analysis from the VQI TCAR Surveillance Project showed lower neurological complications based on embolic events manifested as transient ischemic attack
Limited to small sample size

4. TCAR and tfCAS Trend in the VQI
Background
Objective
Methods
Results
Conclusion
TCAR and tfCAS Trend in the VQI
Year
% CAS performed via TCAR
2016
5.9%
2017
26.0%
2018
46.5%
2019 (April)
56.3%

5. Background
Objective
Methods
Results
Conclusion
Examine perioperative and one-year outcomes of patients undergoing TCAR and tfCAS in the VQI TCAR Surveillance Project.

6. Prospective registry, clinical trial (NCT02850588)
Background
Objective
Methods
Results
Conclusion
Prospective registry, clinical trial (NCT )
Study Period: September 2016 to April 2019
Inclusion -
TCAR and tfCAS procedures for atherosclerotic or intimal hyperplasic disease
Exclusion –
Concomitant planned intracranial procedures
Unknown presenting symptom status or presenting symptom severity
Primary Outcome
In-hospital, 30-day, and 1-year stroke/death
Secondary Outcomes
Stroke, death, myocardial infarction, bleeding complication, procedure time, fluoroscopy time, contrast volume, CMS discharge criteria (failed discharge home or LOS >2 days)
Propensity Score Matched Analysis

7. Baseline Characteristics
Background
Objective
Methods
Results
Conclusion
Baseline Characteristics
tfCAS
N = 6640
TCAR
N = 5251
P-value
Age, y
<.001
Symptomatic
TIA
Stroke
65%
23%
43%
49%
20%
30%
Prior CEA/CAS
21%
17%
Risk Factors
Coronary Artery Disease
Congestive Heart Failure
Hypertension
Chronic Kidney Disease (GFR<60)
44%
16%
89%
35%
51%
19%
91%
40%
.002
CMS High-Risk CEA Criteria
Anatomic
Medical
37%
50%
57%

8. Baseline Characteristics
Background
Objective
Methods
Results
Conclusion
Baseline Characteristics
tfCAS
N = 6640
TCAR
N = 5251
P-value
Preoperative Medications
Aspirin
P2Y12 inhibitors
Statin
87%
77%
83%
90%
89%
<.001
Physician Carotid Stent Volume
Low (0-3)
Medium (4-24)
High (25-87)
24%
56%
20%
26%
18%
.01
Center Carotid Stent Volume
Low (0-14)
Medium (15-66)
59%
23%
25%
16%

9. Propensity Score Matching
Background
Objective
Methods
Results
Conclusion
Propensity Score Matching
3286 Matched Pairs

10. Technical Outcomes tfCAS N = 3286 TCAR P-value Technical Failure 1.2%
Background
Objective
Methods
Results
Conclusion
Technical Outcomes
tfCAS
N = 3286
TCAR
P-value
Technical Failure
1.2%
0.5%
<.001
Unable to access CCA
0.4%
0.1%
.003
Unable to cross carotid lesion
0.6%
0.2%
.002
Unable to deploy stent
.59
Embolic device placement failure
5.8%
0.3%
Unable to insert device
1.0%
Delete?

11. In-Hospital Outcomes tfCAS N = 3286 TCAR P-value Stroke/Death 3.1%
Background
Objective
Methods
Results
Conclusion
In-Hospital Outcomes
tfCAS
N = 3286
TCAR
P-value
Stroke/Death
3.1%
1.6%
<.001
Stroke
2.4%
1.3%
.001
Death
1.0%
0.4%
.008
Myocardial Infarction
0.3%
0.2%
.47
Bleeding Complication
0.8%
.04

12. In-Hospital Outcomes tfCAS N = 3286 TCAR P-value
Background
Objective
Methods
Results
Conclusion
In-Hospital Outcomes
tfCAS
N = 3286
TCAR
P-value
Procedural Time (mins)
.02
Fluoroscopy Time (mins)
<.001
Contrast Volume
Failed CMS Discharge Criteria
Length of stay >2 days
Failed Discharge Home
23%
19%
13%
16%
14%
7.3%

13. Myocardial Infarction 0.3% 0.1% .06 .74
Background
Objective
Methods
Results
Conclusion
Symptomatic
N = 3658
Asymptomatic
N=2876
tfCAS
N = 1829
TCAR
P-value
N = 1438
Stroke/Death
4.2%
2.1%
<.001
1.5%
1.0%
.32
Stroke
3.1%
2.0%
.035
1.3%
0.7%
.13
Death
0.5%
.002
0.2%
0.4%
Myocardial Infarction
0.3%
0.1%
.06
.74
Bleeding Complication
.02
Failed CMS Discharge Criteria
Length of stay >2 days
Failed Discharge Home
32%
26%
21%
22%
18%
11%
9.9%
9.2%
2.8%
10%
9.0%
.80
.85
.18

14. Protamine Use in TCAR No Protamine N = 944 Protamine P-value
Background
Objective
Methods
Results
Conclusion
Protamine Use in TCAR
No Protamine
N = 944
Protamine
P-value
Stroke/Death
2.2%
1.6%
.32
Stroke
2.0%
1.1%
.09
Death
0.7%
0.5%
.56
Myocardial Infarction
0.2%
0.3%
.65
Any Bleeding Complication
8.3%
2.8%
<.001
Interventional treatment
3.6%
1.0%
Blood Transfusion
3.9%
1.2%

15. 30-day Outcomes tfCAS N = 3286 TCAR P-value Stroke/Death 3.7% 1.9%
Background
Objective
Methods
Results
Conclusion
30-day Outcomes
tfCAS
N = 3286
TCAR
P-value
Stroke/Death
3.7%
1.9%
<.001
Stroke
2.5%
1.3%
Death
1.5%
0.8%
.007

16. Freedom From Stroke/Death: 1-Year
Background
Objective
Methods
Results
Conclusion
Freedom From Stroke/Death: 1-Year
TCAR
tfCAS
Number at Risk
Transfemoral
Transcarotid
94.9% vs 90.5%
HR 0.55, 95%CI , P < .001

17. The stroke/death differences persistent up to one-year
Background
Objective
Methods
Results
Conclusion
TCAR is associated with lower rates of stroke and death compared to tfCAS
The stroke/death differences persistent up to one-year
Benefits from TCAR are particularly compelling for symptomatic carotid disease
Protamine use in TCAR results in significantly decreased bleeding complications without differences in thrombotic complications
TCAR with flow reversal should be preferred carotid stenting technique