RS27 - Perioperative and One-Year Outcomes After Transfemoral Carotid Artery Stenting Using Distal Embolic Protection Versus Proximal Balloon Occlusion

Objectives: Transfemoral carotid artery stenting (TFCAS) is associated with an increased risk of periprocedural stroke due to embolization during aortic arch manipulation and lesion crossing. Distal embolic protection (TFCAS-DEP) is widely used but requires crossing the stenotic lesion prior to stent deployment, which may increase embolic risk. Proximal balloon occlusion (TFCAS-PBO) provides an alternative strategy by arresting antegrade flow during intervention, though comparative outcome data remain limited. We compared perioperative and one-year outcomes of TFCAS-DEP versus TFCAS-PBO, stratified by symptomatic status.

Methods: We included all patients undergoing TFCAS in the Vascular Quality Initiative from 2016 through February 2025. Inverse probability weighting was used to adjust for baseline differences between TFCAS-DEP and TFCAS-PBO. Patients were further stratified by symptomatic status; symptomatic patients were defined as those with ipsilateral stroke, transient ischemic attack, or amaurosis fugax within 6 months prior to intervention, while all others were considered asymptomatic. The primary outcome was in-hospital stroke/death, and secondary outcomes were perioperative complications, 30-day mortality, and one-year survival.

Results: A total of 34,884 patients underwent TFCAS, including 34,032 treated with TFCAS-DEP and 852 treated with TFCAS-PBO. Among TFCAS-DEP-treated patients, 19,425 (57.1%) were asymptomatic and 14,607 (42.9%) were symptomatic, while among TFCAS-PBO-treated patients, 524 (61.5%) were asymptomatic and 328 (38.5%) were symptomatic. Among asymptomatic patients, TFCAS-PBO was associated with significantly lower odds of in-hospital stroke/death compared with TFCAS-DEP (aOR 0.23, 95%CI 0.07–0.77; p=0.017). TFCAS-PBO was also associated with lower odds of in-hospital stroke (aOR 0.17, 95%CI 0.04–0.70; p=0.014), any in-hospital neurologic event (aOR 0.40, 95%CI 0.18–0.88; p=0.023), stroke/death/MI (aOR 0.20, 95%CI 0.06–0.68; p=0.010), and shorter length of stay (aOR 0.66, 95%CI 0.47–0.93; p=0.017). At one year, TFCAS-PBO was also associated with improved survival among asymptomatic patients (96.4% vs 93.9%; aHR for mortality 0.55, 95%CI 0.31–0.99; p=0.046). In contrast, among symptomatic patients, no significant differences were observed between protection strategies for in-hospital stroke or death, or any other endpoints (Table I).

Conclusions: In asymptomatic patients, TFCAS-PBO was associated with significantly lower perioperative stroke, stroke/death, fewer neurologic complications, shorter length of stay, and improved one-year survival compared with TFCAS-DEP. There was no difference in outcomes of embolic protection strategies in symptomatic patients indicating that lesion instability increases the risk of procedural neurologic complication regardless of protection methods. These findings suggest that embolic protection strategy selection may be particularly important in asymptomatic carotid intervention and support proximal flow arrest as a potentially advantageous neuroprotection approach in this population.