Propensity score matched analysis of 5-year outcomes of transcarotid revascularization, transfemoral carotid artery stenting, and carotid endarterectomy

Abstract Background Prior studies show variable perioperative mortality after transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), and carotid endarterectomy (CEA), but data beyond the first postoperative year are limited. This study evaluated 5-year mortality and perioperative neurological complication rates after TCAR, TFCAS, and CEA. Methods A retrospective analysis of patients undergoing carotid artery stenting and CEA from 2016 to 2022 was performed using the Vascular Quality Initiative (VQI) database. Patients were propensity score matched using clinically relevant baseline characteristics. Bivariate analysis, Kaplan–Meier survival, and Cox proportional hazards regression were used to evaluate 1- and 5-year mortality, with subgroup analyses based on symptomatic status and perioperative stroke. Results In 2,394 matched CEA–TCAR pairs, 1-year mortality was comparable (2,027 vs 1,923 at risk, p = 0.41), with no difference at 5 years (513 vs 51, p = 0.21). In 2,862 matched CEA–TFCAS pairs, CEA was associated with lower 1-year mortality (2,406 vs 2,397, p < 0.0001), and this difference persisted at 5 years (598 vs 284, p < 0.0001). In 1,758 matched TCAR–TFCAS pairs, TCAR was associated with lower 1-year mortality (1,401 vs 1,468, p = 0.0055), but this difference was no longer significant at 5 years (39 vs 165, p = 0.11). Perioperative stroke rates were low and similar across all comparisons; however, perioperative stroke was associated with significantly higher mortality at both 1 and 5 years. Higher mortality risk was associated with symptomatic status, age ≥ 70 years, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease. Prior percutaneous coronary intervention was associated with lower mortality only in the TCAR–TFCAS comparison. Conclusions CEA and TCAR demonstrated comparable mortality outcomes at 1 and 5 years. In contrast, TFCAS was associated with significantly higher 1-year mortality than both CEA and TCAR, with this difference persisting through 5 years when compared with CEA. Although TCAR showed a 1-year mortality advantage over TFCAS, this difference attenuated over time and was no longer significant at 5 years. These findings support TCAR as a safe and durable alternative to CEA and suggest a less favorable early survival profile with TFCAS.