Results:

During the study period, 5,251 patients underwent transcarotid artery revascularization and 6,640 patients underwent transfemoral carotid artery stenting. After matching, 3,286 pairs of patients who underwent transcarotid artery revascularization or transfemoral carotid artery stenting were identified (transcarotid approach: mean [SD] age, 71.7 [9.8] years; 35.7% women; transfemoral approach: mean [SD] age, 71.6 [9.3] years; 35.1% women). Transcarotid artery revascularization was associated with a lower risk of in-hospital stroke or death (1.6% vs. 3.1%; absolute difference, −1.52% [95% confidence interval {CI}, −2.29% to −0.75%]; relative risk [RR], 0.51 [95% CI, 0.37 to 0.72]; p < 0.001), stroke (1.3% vs. 2.4%; absolute difference, −1.10% [95% CI, −1.79% to −0.41%]; RR, 0.54 [95% CI, 0.38 to 0.79]; p = 0.001), and death (0.4% vs. 1.0%; absolute difference, −0.55% [95% CI, −0.98% to −0.11%]; RR, 0.44 [95% CI, 0.23 to 0.82]; p = 0.008). There was no statistically significant difference in the risk of perioperative myocardial infarction between the two cohorts (0.2% for transcarotid vs. 0.3% for the transfemoral approach; absolute difference, −0.09% [95% CI, −0.37% to 0.19%]; RR, 0.70 [95% CI, 0.27 to 1.84]; p = 0.47). At 1 year using Kaplan-Meier life-table estimation, the transcarotid approach was associated with a lower risk of ipsilateral stroke or death (5.1% vs. 9.6%; hazard ratio, 0.52 [95% CI, 0.41 to 0.66]; p < 0.001). Transcarotid artery revascularization was associated with higher risk of access site complication resulting in interventional treatment (1.3% vs. 0.8%; absolute difference, 0.52% [95% CI, −0.01% to 1.04%]; RR, 1.63 [95% CI, 1.02 to 2.61]; p = 0.04), whereas transfemoral carotid artery stenting was associated with more radiation (median fluoroscopy time, 5 minutes [interquartile range {IQR}, 3 to 7] vs. 16 minutes [IQR, 11 to 23]; p < 0.001) and more contrast (median contrast used, 30 ml [IQR, 20 to 45] vs. 80 ml [IQR, 55 to 122]; p < 0.001).