Comparative Outcomes of Carotid Endarterectomy, Transfemoral Carotid Artery Stenting, and Transcarotid Artery Revascularization in Community Hospital Settings: A Multicenter Retrospective Study.

BACKGROUND

To compare perioperative and 1-year outcomes of carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TF-CAS) using data from a large multicenter real-world cohort of symptomatic patients treated across community hospital settings.

METHODS

A retrospective analysis was performed on 37,482 symptomatic patients who underwent CEA, TCAR, or TF-CAS within the HCA Healthcare system from 2016 to 2023. Symptomatic status was defined by documented ipsilateral stroke, transient ischemic attack (TIA), or amaurosis fugax. Primary outcomes included 90-day stroke, 30-day all-cause mortality, 30-day myocardial infarction (MI), 30-day wound infection, and 1-year restenosis. Multivariable logistic regression with firth correction was used to assess associations between procedure type and outcomes, adjusting for age, Elixhauser comorbidity index, and antiplatelet therapy.

RESULTS

Of the 37,482 patients included in the analysis, 28,021 (74.76%) underwent CEA, 8,603 (22.95%) underwent TF-CAS, and 858 (2.29%) underwent TCAR. The 90-day stroke rates were 2.80% after TCAR, 3.31% after CEA, and 5.96% following TF-CAS (P < 0.0001). Thirty-day mortality was 1.05% after TCAR, 1.07% after CEA, and 3.16% after TF-CAS (P < 0.0001). Rates of MI did not significantly differ across procedure types. No 30-day wound infections occurred in the TCAR group (0/858), compared with 129/28,021 (0.46%) after CEA and 10/8,603 (0.12%) after TF-CAS (P < 0.0001). One-year restenosis rates were low across all modalities; 1.28% after TCAR, 0.85% after CEA, and 0.94% after TF-CAS with no significant adjusted differences between groups (P = 0.35).

CONCLUSION

In this large symptomatic cohort, CEA and TCAR demonstrated similar perioperative safety, while TF-CAS was associated with higher 90-day stroke and 30-day mortality. One-year restenosis rates were low and comparable across all 3 approaches. These findings demonstrate that CEA and TCAR achieve comparably favorable outcomes with low rates of stroke, mortality, and perioperative complications, supporting both as safe and effective options for symptomatic patients. Conversely, TF-CAS was linked to significantly higher stroke risk, underscoring the need for selective use based on anatomy and patient-specific factors. Overall, the results reinforce a personalized, risk-adjusted approach to carotid revascularization.