Carotid Artery Stenting Versus Carotid Endarterectomy for Asymptomatic Carotid Stenosis: A Propensity Score–Matched Real-World Analysis

BACKGROUND AND OBJECTIVES: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are established revascularization strategies for carotid stenosis, yet evidence comparing them in asymptomatic populations remains limited. The Carotid Revascularization Endarterectomy versus Stenting Trial-2 used a parallel-arm design and did not provide a direct head-to-head comparison of CAS vs CEA. This study evaluates real-world long-term outcomes of CAS compared directly with those of CEA in asymptomatic carotid stenosis. METHODS: Adults with asymptomatic carotid stenosis undergoing CAS or CEA between January 2016 and December 2024 were identified from the TriNetX US Collaborative Network. Patients with previous ischemic stroke, TIA, hemorrhage, or posterior-circulation stenosis were excluded. Propensity score matching (1:1) on demographics, comorbidities, and baseline antithrombotic medications yielded 5415 patients per cohort. Primary outcomes were all-cause mortality and ischemic stroke at 5 years; secondary outcomes included intraparenchymal hemorrhage and major bleeding. Kaplan-Meier analyses with log-rank testing and Cox proportional hazards models were used, with outcomes assessed at 6 months, 1, 3, and 5 years. RESULTS: Ischemic stroke occurred in 10.0% of CAS vs 9.8% of CEA patients (cumulative probability 15.85% vs 14.07%; hazard ratio [HR] 1.179, 95% CI 1.045-1.329, P = .007). All-cause mortality was higher after CAS (21.70% vs 18.69%; HR 1.212, 95% CI 1.084-1.355, P = .001). Intraparenchymal hemorrhage was more frequent after CAS (2.11% vs 1.30%; HR 1.940, 95% CI 1.327-2.835, P < .001). Major bleeding rates were comparable (12.10% vs 11.88%; HR 1.130, P = .071). All standardized differences were <0.10 postmatching. CONCLUSION: In real-world practice, CAS for asymptomatic carotid stenosis was associated with modestly higher ischemic stroke, mortality, and intraparenchymal hemorrhage compared with CEA over 5 years, suggesting an association favoring CEA. Prospective studies are needed to establish definitive causal relationships.