Cognitive Outcomes After Carotid Artery Stenting Versus Carotid Endarterectomy in Patients With Asymptomatic Carotid Stenosis: A Propensity Score-Matched Cohort Study.

Background

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Objectives

Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are established carotid revascularization options, but their long-term cognitive outcomes have not been compared directly at scale. We compared new-onset cognitive decline and dementia outcomes after CAS versus CEA for asymptomatic carotid stenosis.

Methods

Using the TriNetX US Collaborative Network, we identified adults undergoing CAS or CEA for asymptomatic carotid stenosis (no prior infarct) without dementia or cognitive impairment at the time of procedure. Cohorts were balanced by 1:1 propensity-score matching on demographics, vascular and neuropsychiatric comorbidities, and antithrombotic medications. The prespecified primary endpoint was a composite of cognitive decline or dementia; cognitive decline and dementia were assessed individually as secondary endpoints. The outcomes were defined using ICD codes and assessed over 1, 3, and 5 years following intervention. A sensitivity analysis was additionally performed, excluding any lifetime cerebral infarction.

Results

The primary analysis yielded 4,822 matched pairs; a sensitivity cohort additionally excluding lifetime cerebral infarction yielded 3,680 pairs. In the primary cohort, CAS was associated with higher 5-year event probabilities than CEA across all three endpoints (cognitive decline 16.68% vs 13.80%, HR 1.29, 1.13-1.48; dementia 5.02% vs 4.13%, HR 1.36, 1.04-1.76; composite 18.06% vs 15.24%, HR 1.29, 1.13-1.46). In the infarct-free sensitivity cohort, the composite and cognitive-decline associations were null at 5 years (composite HR 1.06; cognitive decline HR 0.99), while dementia remained modestly elevated (HR 1.38, 1.01-1.88; p=0.04).

Conclusion

In patients treated for asymptomatic carotid stenosis, CAS was associated with higher rates of incident cognitive decline and dementia than CEA. After excluding patients with lifetime cerebral infarction, the composite and cognitive-decline associations were no longer present, and only a borderline dementia signal remained (HR 1.38, 95% CI 1.01-1.88; p=0.04). This pattern could reflect antecedent infarct burden, contributing to more cognitive symptoms in CAS group. However, further prospective studies are needed to confirm this finding.