Comparison of Complications and Cost for Transfemoral Versus Transcarotid Stenting of Carotid Artery Stenosis

Published:September 19, 2022DOI:


      Options for endovascular treatment of carotid artery disease have been developed to compliment with carotid endarterectomy, transfemoral carotid artery stenting (TFCAS) and a hybrid approach with transcarotid artery revascularization (TCAR). We sought to capture endpoints outside of stroke, myocardial infarction (MI), and death involved with each procedure at our institution as well as evaluate cost.


      Carotid stent procedures performed from 2014 to 2020 at our institution underwent comparative analysis based upon access site and type of stent procedure performed, TFCAS versus TCAR. Procedural details and outcomes were captured prospectively and included in the National Cardiovascular Data Peripheral Vascular Intervention Registry (NCDR-PVI). Further retrospective review was performed to evaluate endpoints beyond stroke, MI, and death. Total in-hospital cost, including administrative, capital and utilities (fixed cost), and labor and supplies (variable cost) were also evaluated.


      One hundred thirty-seven patients were reviewed. Seventy-seven were treated with TFCAS and 60 with TCAR. The mean age was 74 years, predominantly male (68%) and Caucasian (90%). Patients undergoing TFCAS were more likely to be symptomatic compared to those receiving TCAR (81.8% vs. 50.0%, P = <0.001). There were no statistically significant differences in event rates, including mortality, recurrent cerebrovascular accident / transient ischemic attack, or bleeding. Complications not captured in the NCDR-PVI database were more frequent in the TCAR group (21.7% vs. 5.2%, P = 0.004) and included pneumothorax (n = 2), neck hematoma (n = 8), and common carotid artery stenosis or injury (n = 3). Rates of complications in the TFCAS group (n = 4) were lower and limited to groin hematoma (n = 2), central retinal artery occlusion causing vision loss and a case of postoperative dysphagia. Geographic miss of initial stent placement was identified in 15.0% of TCAR patients and 2.6% (P = 0.008) of TFCAS patients. Restenosis rates on duplex ultrasound were similar between the two groups (14.6% of patients) and were not associated with symptoms. The mean follow-up interval was similar for both groups of 31.8 months for TCAR and 30.7 months for TFCAS (P = 0.797). There was a statistically significant difference in total cost with TCAR being more expensive ($22,315 vs. $11,001) driven by direct costs that included devices, imaging, and extended length of stay in the TCAR group (P < 0.001). There was no significant difference between stroke free survival (91.1% vs. 88.6%, P = 0.69) and mortality (78.1% vs. 85.2%, P = 0.677) at 3 years follow-up between TCAR and TFCAS, respectively.


      Both TFCAS and TCAR provide similar 3-year stroke and mortality risk/benefit and are distinctly different procedures. Both should be evaluated independently with analysis of variables beyond stroke, death, and MI. TFCAS is more cost-effective than TCAR in this single institution study.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Clark R.M.
        • Curci J.A.
        Pneumothorax, pneumomediastinum, and dysphonia complicating awake transcarotid artery revascularization.
        J Vasc Surg Cases Innov Tech. 2020; 6: 133-135
        • Kashyap V.
        • Schneider P.
        • Foteh M.
        • et al.
        Early outcomes in the ROADSTER 2 study of transcarotid artery revascularization in patients with significant carotid artery disease.
        Stroke. 2020; 51: 2620-2629
        • Kwolek C.J.
        • Jaff M.R.
        • Leal J.I.
        • et al.
        Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal.
        J Vasc Surg. 2015; 62: 1227-1234.e1
        • Malas M.B.
        • Leal Lorenzo J.I.
        • Nejim B.
        • et al.
        Analysis of the ROADSTER pivotal and extended-access cohorts shows excellent 1-year durability of transcarotid stenting with dynamic flow reversal.
        J Vasc Surg. 2019; 69: 1786-1796
        • Coelho A.
        • Prassaparo T.
        • Mansilha A.
        • et al.
        Critical appraisal on the quality of reporting on safety and efficacy of transcarotid artery stenting with flow reversal.
        Stroke. 2020; 51: 2863-2871
        • Schermerhorn M.L.
        • Liang P.
        • Dakour-Aridi H.
        • et al.
        In-hospital outcomes of transcarotid artery revascularization and carotid endarterectomy in the society for vascular surgery vascular quality initiative.
        J Vasc Surg. 2020; 71: 87-95
        • Malas M.B.
        • Dakour-Aridi H.
        • Wang G.J.
        • et al.
        Transcarotid artery revascularization versus transfemoral carotid artery stenting in the society for vascular surgery vascular quality initiative.
        J Vasc Surg. 2019; 69: 92-103.e2
        • Sagris M.
        • Giannopoulos S.
        • Giannopoulos S.
        • et al.
        Transcervical carotid artery revascularization: a systematic review and meta-analysis of outcomes.
        J Vasc Surg. 2021; 74: 657-665.e12
        • Park B.
        • Mavanur A.
        • Dahn M.
        • et al.
        Clinical outcomes and cost comparison of carotid artery angioplasty with stenting versus carotid endarterectomy.
        J Vasc Surg. 2006; 44: 270-276
        • Pearce W.H.
        • Parker M.A.
        • Feinglass J.
        • et al.
        The importance of surgeon volume and training in outcomes for vascular surgical procedures.
        J Vasc Surg. 1999; 29: 768-778
        • Lal B.K.
        • Cambria R.
        • Moore W.
        • et al.
        Evaluating the optimal training paradigm for transcarotid artery revascularization based on worldwide experience.
        J Vasc Surg. 2022; 75: 581-589.e1
        • Coelho A.P.
        • Lobo M.
        • Nogueira C.
        • et al.
        Overview of evidence on risk factors and early management of acute carotid stent thrombosis during the last two decades.
        J Vasc Surg. 2019; 69: 952-964
        • Moulakakis K.G.
        • Kakisis J.
        • Tsivgoulis G.
        • et al.
        Acute early carotid stent thrombosis. A case series.
        Ann Vasc Surg. 2017; 45: 69-78
        • Paraskevas K.I.
        • Mikhailidis Dimitri P.
        • Veith Frank J.
        Mechanisms to explain the poor results of carotid artery stenting (CAS) in symptomatic patients to date and options to improve CAS outcomes.
        J Vasc Surg. 2010; 52: 1367-1375
        • Ferguson G.G.
        • Eliasziw M.
        • Barr H.W.K.
        • et al.
        The North American symptomatic carotid endarterectomy trial: surgical results in 1415 patients.
        Stroke. 1999; 30: 1751-1758
        • Walker M.D.
        • Marler J.R.
        • Goldstein M.
        • et al.
        Endarterectomy for asymptomatic carotid artery stenosis.
        JAMA. 1995; 273: 1421-1428
        • Nallamothu B.K.
        • Gurm H.S.
        • Ting H.H.
        • et al.
        Operator experience and carotid stenting outcomes in medicare beneficiaries.
        JAMA. 2011; 306: 1338-1343
        • Sgroi M.D.
        • Darby G.C.
        • Kabutey N.
        • et al.
        Experience matters more than specialty for carotid stenting outcomes.
        J Vasc Surg. 2015; 61: 933-938
        • Kumins N.H.
        • Kashyap V.S.
        Learning curve and proficiency of transcarotid artery revascularization compared to transfemoral carotid artery stenting.
        Semin Vasc Surg. 2020; 33: 16-23
        • Sardar P.
        • Chatterjee S.
        • Aronow H.D.
        • et al.
        Carotid artery stenting versus endarterectomy for stroke prevention: a meta-analysis of clinical trials.
        J Am Coll Cardiol. 2017; 69: 2266-2275
        • Leal I.
        • Orgaz A.
        • Flores Á.
        • et al.
        A diffusion-weighted magnetic resonance imaging-based study of transcervical carotid stenting with flow reversal versus transfemoral filter protection.
        J Vasc Surg. 2012; 56: 1585-1590
        • Malas M.B.
        • Aridi H.D.
        • Kashyap V.S.
        • et al.
        Outcomes of transcarotid revascularization with dynamic flow reversal versus carotid endarterectomy in the transcarotid revascularization surveillance project.
        J Vasc Surg. 2019; 69: e95-e96
        • Schermerhorn M.L.
        • Liang P.
        • Eldrup-Jorgensen J.
        • et al.
        Association of transcarotid artery revascularization vs transfemoral carotid artery stenting with stroke or death among patients with carotid artery stenosis.
        JAMA. 2019; 322: 2313-2322
        • Lin J.C.
        • Kolvenbach R.R.
        • Pinter L.
        Protected carotid artery stenting and angioplasty via transfemoral versus transcervical approaches.
        Vasc Endovascular Surg. 2005; 39: 499-503
        • Malas M.B.
        • Elsayed N.
        • Naazie I.
        • et al.
        Propensity score-matched analysis of 1-year outcomes of transcarotid revascularization with dynamic flow reversal, carotid endarterectomy, and transfemoral carotid artery stenting.
        J Vasc Surg. 2022; 75: 213-222.e1
        • Eckstein H.
        • Ringleb P.
        • Allenberg J.
        • et al.
        Results of the stent-protected angioplasty versus carotid endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial.
        Lancet Neurol. 2008; 7: 893-902
        • Gurm H.S.
        • Yadav J.S.
        • Fayad P.
        • et al.
        Long-term results of carotid stenting versus endarterectomy in high-risk patients.
        N Engl J Med. 2008; 358: 1572-1579
        • Gomes M.
        • Soares M.O.
        • Dumville J.C.
        • et al.
        Cost-effectiveness analysis of general anaesthesia versus local anaesthesia for carotid surgery (GALA trial).
        Br J Surg. 2010; 97: 1218-1225
        • de Vries E.E.
        • Baldew V.G.M.
        • den Ruijter H.M.
        • et al.
        Meta-analysis of the costs of carotid artery stenting and carotid endarterectomy.
        Br J Surg. 2017; 104: 1284-1292
        • Mahoney E.M.
        • Greenberg D.
        • Lavelle T.A.
        • et al.
        Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: results from the SAPPHIRE trial.
        Catheter Cardiovasc Interv. 2011; 77: 463-472
        • Almekhlafi M.A.
        • Hill M.D.
        • Wiebe S.
        • et al.
        When is carotid angioplasty and stenting the cost-effective alternative for revascularization of symptomatic carotid stenosis? A Canadian health system perspective.
        AJNR. 2014; 35: 327-332
        • Kanitra J.J.
        • Graham I.A.
        • Hayward R.D.
        • et al.
        Estimated cost of transcarotid arterial revascularization compared with carotid endarterectomy and transfemoral carotid stenting.
        Curēus (Palo Alto, CA). 2022; 14: e23539