Vascular community split over “death” of traditional carotid stenting

A debate at the 2023 Charing Cross (CX) International Symposium (25–27 April, London, UK) between two prominent carotid interventionists—Peter Schneider (University of California San Francisco, San Francisco, USA) and Domenico Valenti (King’s College London, London, UK)—revealed that the vascular community is currently divided over the benefits of transcarotid artery revascularisation (TCAR), as compared to percutaneous carotid artery stenting (CAS).

SCHNEIDER KICKED OFF the debate by arguing in favour of TCAR, initially outlining some of the limitations of percutaneous CAS that prior studies have demonstrated—for example, unwanted events relating to manipulation of the aortic arch as well as incomplete particulate capture. He went on to query whether there is a “better way” to treat carotid artery disease, positing that TCAR may offer a solution that overcomes these limitations.

Once again referring to the current literature in this space, he noted that TCAR can enable greater neuroprotective capabilities; improved safety in symptomatic patients and octogenarians; and carries a more efficient learning curve, versus percutaneous stenting.

After reiterating the “unresolved challenges” CAS faces, including those relating to the aortic arch and particulate capture, Schneider concluded that prospective TCAR studies and his own experiences have shown both safety and efficacy with the procedure, demonstrating outcomes that are “competitive” with carotid endarterectomy (CEA) and “substantially better” than percutaneous stenting.

Offering a riposte to these assertions, Valenti stated that TCAR—in essence, at least— has been around for many years, and is therefore not the “disruptive technology” within carotid interventions it is sometimes presented as, also claiming that his opponent and other TCAR advocates have been “mesmerised” by the existing data.

Homing in on said data, Valenti challenged positive conclusions drawn from the results of the ROADSTER 2 trial, noting its non-randomised nature, low proportion of symptomatic patients and, “more importantly”, lack of stratified data on delay to treatment. Additionally, he told attendees that findings from the Society for Vascular Surgery’s (SVS) Vascular Quality Initiative (VQI) are also limited by selection biases, gaps in the data, and the fact they come from a nonrandomised trial.

Finally, Valenti noted that CAS has been subject to far more “intense scrutiny” than TCAR to date—for example, in the CREST, ICSS and SPACE randomised controlled trials (RCTs).

And, while he commented that TCAR may yet prove useful in certain patients, they are yet to be identified, and the lack of RCT-derived evidence supporting it means the “death” of percutaneous stenting is not imminent.

An audience poll produced a close result, but ultimately saw more CX attendees concur with Valenti’s closing gambit that “TCAR is not about to send CAS to oblivion”, as 52% voted against the statement that ‘TCAR is better than percutaneous carotid stenting’.