Comparative Learning Curves in Carotid Artery Stenting: TCAR Is More Forgiving Than TFCAS

Document Type

Conference Proceeding

Publication Date

9-1-2025

Publication Title

J Vasc Surg

Abstract

Objectives: To compare the learning curves for transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (tfCAS). Methods: Patients undergoing TCAR or tfCAS from 2005 to 2024 were identified in the Vascular Quality Initiative registry. Operator experience was measured by numbering each physician’s cases chronologically. Stroke was the primary outcome; secondary outcomes included major adverse cardiovascular events (MACEs) and procedural metrics (procedure time, fluoroscopy time, contrast volume). A machine learning model predicted outcome risk based on experience. Proficiency was defined as the point when predicted outcomes fell below the overall mean. Learning curves were generated over time and stratified by symptomatic status. Results: The study included 48,538 TCAR and 37,561 tfCAS procedures, averaging 20 TCAR and 16 tfCAS procedures per operator. Stroke rates declined with experience for both procedures. In TCAR, symptomatic patient rates fell from 1.9% (95% confidence interval [CI], 1.6%-2.1%) to 0.85% (95% CI, 0.8%-0.9%), reaching the mean by 37 cases (Fig 1). For tfCAS, symptomatic rates declined from 3.0% (95% CI, 1.95%-4.2%) to 1.5% (95% CI, 1.45%-1.61%), reaching the mean by 40 cases (Fig 1). MACE outcomes followed similar improvement trends with increased experience. Operative time declined from 79 minutes (95% CI, 76-81) to 40 minutes (95% CI, 37-41) in TCAR, reaching the average by case 23 (Fig 2); in tfCAS, time dropped from 76 minutes (95% CI, 74-78) to 56 minutes (95% CI, 54-58), reaching average by case 25 (Fig 2). Other technical efficiency metrics followed similar improvement patterns. Conclusions: While both TCAR and tfCAS show improved performance with experience, their learning curves are distinct. TCAR has low complication rates from the outset, with no significant change in slope over time. In contrast, tfCAS shows marked improvement until 50 cases, after which it runs parallel to the TCAR curve. The curves never converge, with TCAR maintaining lower complication rates at all experience levels. These findings suggest TCAR is a safer, more accessible option for a broader range of operators, while tfCAS requires higher-volume specialization to reduce risk. [Formula presented] [Formula presented]

Volume

82

First Page

e54

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