CEA Safest Urgent Revascularization Method for Symptomatic Carotid Artery Stenosis

Researchers compared in-hospital outcomes of carotid endarterectomy, transcarotid artery revascularization, and transfemoral carotid stenting.

Carotid endarterectomy (CEA) was found to be the safest method of revascularization during any time period, according to results of a retrospective cohort study published in the journal Stroke.

Researchers sourced data from the Society for Vascular Surgery Vascular Quality Initiative, which was a national quality improvement registry that collected information about 12 types of vascular procedures from over 400 centers in North America between 2016 and 2019. Urgent procedures were defined as taking place 0-2 days from latest symptoms, early procedures 3-14 days, and late revascularization at 15-180 days. Outcomes of CEA, transcarotid artery revascularization (TCAR), and transfemoral carotid stenting (TFCAS) were assessed on the basis of procedure timing.

Among the 18,643 patients included in this analysis, 10.8% underwent urgent, 39.8% early, and 49.4% late revascularization. Nearly all baseline features were significant on the basis of procedure. Patients who underwent TCAR tended to be older with more comorbidities, CEA recipients were more likely to present with stroke, and TFCAS recipients were more likely to receive general anesthesia.

Among urgent procedures, most (55.4%) were CEA, followed by TFCAS (37.4%), and TCAR (7.2%). Rates of in-hospital stroke or death were lower among CEA recipients (4.0% vs 6.9% vs 5.6%; P =.02), and in-hospital transient ischemic attack (TIA) were lower among CEA and TFCAS recipients (0.6% vs 0.4% vs 3.5%; P =.01) compared with TCAR, respectively.

TCAR and CEA did not differ for in-hospital stroke or death following an urgent procedure (odds ratio [OR], 1.9; 95% CI, 0.9-4.0; P =.10). Compared with CEA, TFCAS associated with increased risk for stroke or death (OR, 1.7; 95% CI, 1.0-2.9; P =.03), primarily driven by mortality (OR, 4.3; 95% CI, 2.0-9.4; P <.001).

For early revascularization, 69.1% underwent CEA, 18.4% TFCAS, and 12.5% TCAR. The rates among patients who underwent CEA, TFCAS, and TCAR for in-hospital stroke or death (2.5% vs 3.8% vs 2.9%; P =.05); TIA (0.6% vs 1.4% vs 1.1%; P =.01); death (0.6% vs 1.3% vs 1.0%; P =.03); stroke or TIA (2.7% vs 4.2% vs 3.6%; P =.02); and stroke, death, or myocardial infarction (3.0% vs 4.5% vs 3.2%; P =.04) differed significantly, respectively.

Risk for in-hospital stroke or death was increased among TFCAS recipients compared with CEA (OR, 1.6; 95% CI, 1.1-2.4; P =.01).

The late revascularization recipients underwent CEA (65.8%), TFCAS (17.6%), and TCAR (16.7%). Compared with CEA, TFCAS associated with increased risk for in-hospital stroke or death (OR, 1.9; 95% CI, 1.2-3.0; P =.009). No significant difference was observed between CEA and TCAR (OR, 1.5; 95% CI, 0.9-2.3; P =.08).

This study was limited by not assessing longer-term outcomes. However, previous analyses have indicated that most postoperative complications occur within 3 days of index procedure.

“These results suggest that urgent revascularization is safest with CEA but, in all other timing strata, TCAR and CEA have comparable outcomes,” the study authors noted.

Disclosure: An author declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Cui CL, Dakour-Aridi H, Lu JJ, Yei KS, Schermerhorn ML, Malas MB. In-hospital outcomes of urgent, early, or late revascularization for symptomatic carotid artery stenosis. Stroke. Published online December 7, 2021. doi:10.1161/STROKEAHA.120.032410