The Unexplored Dimension of Crest-2: The Role of Procedural Efficiency in Asymptomatic Carotid Stenosis Outcomes

Document Type

Conference Proceeding

Publication Date

7-1-2026

Publication Title

J Vasc Surg

Keywords

adult, aged, carotid artery, carotid artery stenting, carotid endarterectomy, carotid stenosis, cerebrovascular accident, conference abstract, controlled study, female, human, major clinical study, male, mortality rate, operation duration, special situation for pharmacovigilance, surgery

Abstract

Objectives: The CREST-2 trial demonstrated favorable outcomes with trans-femoral carotid artery stenting (tfCAS) compared with carotid endarterectomy (CEA) for the treatment of asymptomatic carotid artery stenosis. Nevertheless, participation in CREST-2 required substantially more stringent operator credentialing for tfCAS compared to CEA operators, thus creating an imbalance that may have influenced outcomes. This study investigates operative time as a pragmatic surrogate of technical performance to evaluate its association with perioperative outcomes across carotid revascularization strategies. Methods: Patient undergoing carotid revascularization for asymptomatic carotid artery stenosis between January 2016 and December 2024 were identified in the Society for Vascular Surgery Vascular Quality Initiative. Asymptomatic carotid artery stenosis was defined as >70% stenosis without any neurological event within the preceding six months. The primary outcome of perioperative stroke or death was evaluated as a continuous function of operative time. Results: Among 240,738 patients who underwent carotid revascularization for asymptomatic carotid stenosis during the study period, 14% (n = 33,338) underwent tfCAS, 25% (n = 61,627) underwent TCAR, and 61% (n = 145,773) underwent CEA. Median operative times were 55 minutes (interquartile range [IQR], 41-75 minutes) for tfCAS, 63 minutes (IQR, 49-80 minutes) for TCAR, and 107 minutes (IQR, 84-135 minutes) for CEA. At shorter operative durations, perioperative stroke/death rates were comparable between tfCAS and CEA at 0.4% (95% CI, 0.3%-0.5%). With increasing operative time, the risk of stroke/death following tfCAS rose progressively beyond 30 minutes, reaching 2.2% (95% CI, 2.2%-2.2%) at 180 minutes. In contrast, stroke/death rates after CEA remained stable between 0.4% and 0.5% across operative durations up to 200 minutes (Fig). TCAR demonstrated stable perioperative stroke or death rates between 1.0% and 1.1% across operative times and was associated with more favorable outcomes compared to tfCAS once tfCAS operative duration exceeded 75 minutes. Conclusions: Operative time is differentially associated with stroke or death across carotid revascularization strategies in asymptomatic carotid stenosis. Although tfCAS and CEA demonstrate comparable outcomes at shorter operative durations, prolonged tfCAS procedures are associated with a progressive increase in perioperative risk, whereas outcomes following CEA remain largely unchanged. These findings identify operative time as a clinically relevant and under-recognized determinant of perioperative outcomes after tfCAS, a factor that remains largely unstudied in the CREST-2 trial. [Formula presented]

Volume

84

Issue

1

First Page

e148

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