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Objective: To compare the outcomes of TCAR with flow reversal to the gold standard CEA using data from the Society for Vascular Surgery Vascular Quality Initiative TCAR Surveillance Project. Summary of Background Data: TCAR is a novel minimally invasive procedure for carotid revascularization in high-risk patients that is associated with significantly lower stroke rates compared with carotid artery stenting via the transfemoral approach. Methods: Patients in the United States and Canada who underwent TCAR and CEA for carotid artery stenosis (2016-2019) were included. Propensity scores were calculated based on baseline clinical variables and used to match patients in the 2 treatment groups (n = 6384 each). The primary endpoint was the combined outcome of perioperative stroke and/or death.Results: No significant differences were observed between TCAR and CEA in terms of in-hospital stroke/death [TCAR, 1.6% vs CEA, 1.6%, RR (95% CI): 1.01 (0.77-1.33), P = 0.945], stroke [1.4% vs 1.4%, RR (95% CI): 1.02 (0.76-1.37), P = 0.881], or death [0.4% vs 0.3%, RR (95% CI): 1.14 (0.64-2.02), P = 0.662]. Compared to CEA, TCAR was associated with lower rates of in-hospital myocardial infarction [0.5% vs 0.9%, RR (95% CI): 0.53 (0.35-0.83), P = 0.005], cranial nerve injury [0.4% vs 2.7%, RR (95% CI): 0.14 (0.08-0.23), P < 0.001], and postprocedural hypertension [13% vs 18.8%, RR (95% CI): 0.69 (0.63-0.76), P < 0.001]. They were also less likely to stay in the hospital for more than 1 day [26.4% vs 30.1%, RR (95% CI): 0.88 (0.82-0.94), P < 0.001]. No significant interaction was observed between procedure and symptomatic status in predicting postoperative outcomes. At 1 year, the incidence of ipsilateral stroke or death was similar between the 2 groups [HR (95% CI): 1.09 (0.87-1.36), P = 0.44]. Conclusions: This propensity-score matched analysis demonstrated significant reduction in the risk of postoperative myocardial infarction and cranial nerve injury after TCAR compared to CEA, with no differences in the rates of stroke/death.

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The Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia trial (BEST-CLI) is an international, prospective, multicentre, multidisciplinary and pragmatic, open-label, superiority-based, comparative-effectiveness randomised controlled trial designed to address the knowledge gap in choosing the appropriate therapy for the treatment of critical limb ischaemia (CLI). This study compares the effectiveness of the best available surgical treatment with the best available endovascular treatment in adults with CLI who are eligible for both treatment options. The study has completed its enrolment phase and patients included in the study are currently being followed up to 50 months. Results of the study promise to provide us with answers to several questions regarding treatment options for patients with CLI, more recently referred to as chronic limb-threatening ischaemia.

Objectives: Limited available data suggests the incidence of carotid artery occlusion (CAO) is declining, and if detected, the association with acute stroke is very low. We report our long-term stroke outcomes in patients with CAO in an integrated health system.Methods: We identified adult patients with evidence of CAO at initial imaging from 2008 to 2012 or identified during follow-up through 2017 without prior carotid intervention. The primary outcome was acute ischemic stroke (AIS) attributed to the carotid artery (any ipsilateral stroke within the anterior circulation, including internal capsule, basal ganglia, and thalamus). Timing of stroke was assessed in three intervals: >6 months prior to CAO imaging, within 6 months of CAO including the time of imaging study acquisition, and in follow-up until study endpoint. Secondary outcomes include ischemic stroke of other etiology and/or location, and survival.Results: Among over 94,800 eligible patients with carotid imaging, 2084 arteries in 2044 patients were identified with CAO, including 1787 arteries (85.8%) occluded at baseline and 297 arteries (14.3%) that occluded in follow-up. The mean age was 71 6 11 years, and 35.6% of patients were female. The mean maximal follow-up was 4.8 6 3.1 years. Of patients that occluded in follow-up, 37, 60, and 189 CAO were seen with baseline arteries with mild/none, moderate, and severe stenosis, respectively. The mean time of progression to occlusion (without interceding intervention) was 3.2 6 2.2 years for arteries with no/mild stenosis, 3.5 6 2.4 years for arteries with moderate stenosis, and 1.5 6 2.0 years for arteries with severe stenosis. In total, 366 ipsilateral AIS events (17.6%) occurred in 346 arteries, with 297 strokes in arteries occluded at baseline and 69 in arteries that occluded in follow-up. The majority of carotid-related strokes (79.2%) occurred within 6 months prior to CAO (Table ). After ipsilateral AIS, 5 patients (11.6%) died within 30 days, an additional 8 patients (18.6%) within 1 year, and 16 patients (37.2%) were alive at the end of follow-up. The overall mortality rate was 43.5%, with 13.9% of patients lost to follow-up. There were 370 other strokes (17.8%) observed in 350 arteries, including 308 contralateral strokes in 288 arteries and 62 ipsilateral strokes not attributable to carotid disease. Conclusions:The observed incidence of CAO is low in this select cohort of patients; however, the incidence of carotid-related stroke and associated short-and long-term mortality is high. Further investigation is needed to identify patients at risk of progression to CAO to prevent the associated morbidity and mortality of stroke.