RS28 - Carotid endarterectomy has improved long-term stroke and survival compared to carotid artery stenting in a real-world propensity-matched cohort analysis using the TriNetX Network

Objectives: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are established treatments for carotid stenosis, yet real-world comparative effectiveness data across large, diverse patient populations remain limited, particularly regarding long-term outcomes. The recently published CREST 2 trial suggested that CAS reduced stroke risk up to four years compared to intensive medical therapy alone, whereas CEA did not. However, both patient and interventionalist inclusion and exclusion criteria were highly selective and may not reflect real-world practice and outcomes. This study aims to compare perioperative and long-term outcomes of CEA and CAS in asymptomatic patients using the TriNetX Network, a multi-institutional electronic health record (EHR) platform providing continuously updated, aggregated real-world data from healthcare organizations worldwide.

Methods: Using the TriNetX US Collaborative Network, adult patients with asymptomatic carotid artery disease who underwent CEA or CAS between January 2005 and January 2025 were identified. A 1:1 propensity score match (PSM) was performed based on demographics, comorbidities, and relevant medications to balance baseline characteristics. Primary outcomes included stroke, mortality, and the composite outcome of stroke or death at 30 days, 1 year, 3 years, and 5 years.

Results: A total of 101,714 patients were included in the analysis (CEA: 61,124 [60.1%]; CAS: 40,590 [39.9%]). PSM yielded 39,471 matched patients in each cohort with balanced baseline characteristics (Table I). The CEA group showed consistently lower rates of stroke at 30 days (2.0% vs 2.4%, p=0.001), 1 year (2.9% vs 3.3%, p=0.001), 3 years (3.6% vs 3.9%, p=0.008), and 5 years (4.1% vs 4.4%, p=0.038). Three-year mortality was significantly lower following CEA (11.8% vs 12.4%, p=0.014), while other time points showed similar rates. The composite outcome of stroke or death favored the CEA group at every interval, with significant differences observed at 30 days (3.9% vs 4.2%, p=0.049), 1 year (8.7% vs 9.4%, p=0.001), 3 years (14.9% vs 15.8%, p< 0.001), and 5 years (20.1% vs 20.8%, p=0.013) (Figure 1).

Conclusions: In a large, real-world propensity-matched cohort analysis of asymptomatic patients, CEA was associated with improved long-term outcomes, demonstrating significantly lower risk of stroke and mortality compared with CAS. While early postoperative outcomes were similar between procedures, these findings suggest that procedural selection significantly influences long-term neurologic and survival outcomes in asymptomatic carotid disease.