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Patric Liang, MD1Jack L. Cronenwett, MD2Eric A. Secemsky, MD3; et al
Key Points 
Question Should transcarotid artery revascularization be expanded to patients with standard surgical risk?
Findings In this cohort study of 2962 patients with standard surgical risk who underwent transcarotid artery revascularization and 8886 who underwent carotid endarterectomy, the composite risk of 30-day stroke, death, and myocardial infarction or 1-year ipsilateral stroke was not significantly different after transcarotid artery revascularization or carotid endarterectomy.
Meaning Transcarotid artery revascularization was associated with a similar risk of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke in patients with standard surgical risk undergoing carotid endarterectomy compared with those undergoing transcarotid artery revascularization.
Importance Carotid artery stenting has been limited to use in patients with high surgical risk; outcomes in patients with standard surgical risk are not well known.
Objective To compare stroke, death, and myocardial infarction outcomes following transcarotid artery revascularization vs carotid endarterectomy in patients with standard surgical risk.
Design, Setting, and Participants This retrospective propensity-matched cohort study was conducted from August 2016 to August 2019 with follow-up until August 31, 2020, using data from the multicenter Vascular Quality Initiative Carotid Artery Stent and Carotid Endarterectomy registries. Patients with standard surgical risk, defined as those lacking Medicare-defined high medical or surgical risk characteristics and undergoing transcarotid artery revascularization (n = 2962) or carotid endarterectomy (n = 35 063) for atherosclerotic carotid disease. In total, 760 patients were excluded for treatment of multiple lesions or in conjunction with other procedures.
Exposures Transcarotid artery revascularization vs carotid endarterectomy.
Main Outcomes and Measures The primary outcome was a composite end point of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke.
Results After 1:3 matching, 2962 patients undergoing transcarotid artery revascularization (mean [SD] age, 70.4 [6.9] years; 1910 [64.5%] male) and 8886 undergoing endarterectomy (mean [SD] age, 70.0 [6.5] years; 5777 [65.0%] male) were identified. There was no statistically significant difference in the risk of the primary composite end point between the 2 cohorts (transcarotid 3.0% vs endarterectomy 2.6%; absolute difference, 0.40% [95% CI, −0.43% to 1.24%]; relative risk [RR], 1.14 [95% CI, 0.87 to 1.50]; P = .34). Transcarotid artery revascularization was associated with a higher risk of 1-year ipsilateral stroke (1.6% vs 1.1%; absolute difference, 0.52% [95% CI, 0.03 to 1.08]; RR, 1.49 [95% CI, 1.05 to 2.11%]; P = .02) but no difference in 1-year all-cause mortality (2.6% vs 2.5%; absolute difference, −0.13% [95% CI, −0.18% to 0.33%]; RR, 1.04 [95% CI, 0.78 to 1.39]; P = .67).
Conclusions and Relevance In this study, the risk of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke was similar in patients undergoing transcarotid artery revascularization compared with those undergoing endarterectomy for carotid stenosis.
