Abstract 4371916: Transcarotid Artery Revascularisation (TCAR) versus Transfemoral Carotid Artery Stenting (TFCAS) versus Carotid Endarterectomy (CEA) for Treatment of Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis of Intra-Hospital Mortality and Stroke

Abstract

Introduction: Carotid artery stenosis (CAS) is a significant cause of stroke, and its optimal surgical management remains debated. While carotid endarterectomy (CEA) has been the gold standard, transcarotid artery revascularisation (TCAR) and transfemoral carotid artery stenting (TFCAS) have emerged as less invasive alternatives. However, comparative data on their perioperative and postoperative outcomes are limited. This network meta-analysis (NMA) evaluates the relative safety of TCAR, TFCAS, and CEA in terms of mortality and stroke in patients suffering from CAS. Research Question: What are the comparative outcomes of TCAR, TFCAS, and CEA in terms of intra-hospital mortality, intra-hospital stroke, intra-hospital myocardial infarction (MI), and transient ischemic attack (TIA) in patients with CAS? Methodology: We conducted a Bayesian NMA using a random-effects model, synthesising data from 11 studies (n=157,767 patients). The analysis included direct and indirect comparisons between TCAR, TFCAS, and CEA. Primary outcomes were intra-hospital mortality and stroke, with secondary outcomes of MI and TIA. We calculated odds ratios (OR) with 95% credible intervals (CrI) and ranked treatments using surface under the cumulative ranking curve (SUCRA) probabilities. Multi-criteria decision analysis (MCDA) was used to rank interventions on the basis of all outcomes. Results: Our NMA included 11 studies involving 157,767 patients. For intra-hospital mortality, TCAR showed a trend toward lower mortality compared to TFCAS (OR 0.59, 95% CrI 0.33–1.05) and CEA (OR 0.87, 95% CrI 0.38–1.98), ranking highest (SUCRA 76.3%). For intra-hospital stroke, TCAR was superior to TFCAS (OR 0.50, 95% CrI 0.34–0.74) and comparable to CEA (OR 1.82, 95% CrI 0.96–3.45), again ranking highest (SUCRA 83.5%). TFCAS consistently performed worst for both mortality (SUCRA 15.6%) and stroke (SUCRA 20.3%). No significant differences were observed for MI (TCAR SUCRA 61.4%, CEA 52.8%, TFCAS 35.8%) or TIA (TCAR SUCRA 81.2%, CEA 48.6%, TFCAS 20.2%). This NMA demonstrates that TCAR is associated with the most favourable outcomes for perioperative mortality and stroke prevention, outperforming TFCAS and showing comparable safety to CEA. TFCAS consistently ranked lowest for safety endpoints, suggesting it should be used selectively.