Asymptomatic Patients With a Remote History of Transient Ischemic Attack or Stroke May Benefit From Reduced Hazard of In-hospital Death After Transcarotid Artery Revascularization

Abstract

Asymptomatic patients with remote history of transient ischemic attack (TIA) or stroke are not well-studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients with and without a history of TIA or stroke. Data from patients in the Vascular Quality Initiative database undergoing TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) were analyzed. Symptomatic status was defined as TIA and/or stroke within 180 days before procedure. Asymptomatic status was divided into patients with no history of TIA/stroke (asymptomatic A) and TIA and/or stroke occurring more than 180 days before the procedure (asymptomatic B). The Student t test and χ2 test were used to compare baseline patient characteristics and outcomes. Multivariate logistic regression was used to adjust for significant between-group differences in baseline characteristics. There were 7158 patients who underwent TCAR (symptomatic: 2574; asymptomatic A: 3689; asymptomatic B: 895) and 18,023 patients who underwent TFCAS (symptomatic: 6195; asymptomatic A: 10,333; asymptomatic B: 1495). TCAR patients were generally older, White, smokers, and had more comorbidities than TFCAS. Asymptomatic B patients had higher rates of TIA, stroke, TIA/stroke, stroke/death, and stroke/death/myocardial infarction than asymptomatic A patients, and these rates were similar to those of symptomatic patients (Table). Comparing TCAR and TFCAS among asymptomatic B patients, there were statistically significant reductions in the odds of stroke/death (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.27-0.84; P = .011) and stroke/death/myocardial infarction (OR, 0.51; 95% CI, 0.30-0.87; P = .013) after TCAR. A greater reduction in the odds of death was observed among asymptomatic B patients (OR, 0.30; 95% CI, 0.084-1.110; P = .069) compared with asymptomatic A patients (OR, 0.41; 95% CI, 0.20-0.85; P = .017), which was likely driven by the increased rate of death for TFCAS asymptomatic B patients (0.9%) compared with asymptomatic A (0.6%) Asymptomatic patients with a remote history of TIA/stroke do not have the same outcomes as asymptomatic patients without a history of TIA/stroke and are at higher risk of adverse in-hospital events. Asymptomatic patients with a remote history of TIA/stroke have increased risk of in-hospital death after TFCAS and may benefit from TCAR.TablePercent incidence and adjusted odds ratio (aORs) for in-hospital outcomesIn-hospital eventsSymptomaticAsymptomatic A: No history of TIA/strokeAsymptomatic B: Remote history of TIA/StrokeTCAR (%)TFCAS (%)Odd ratio (95% CI)P valueTCARTFCASOdd ratio (95% CI)P valueTCARTFCASOdd ratio (95% CI)P valueTIA0.710.66 (0.39-1.13).130.40.60.60 (0.31-1.16).131.11.30.76 (0.34-1.70).50Stroke2.13.10.63 (0.46-0.87).0040.81.40.50 (0.32-0.78).0021.92.50.70 (0.38-1.28).25Death0.62.70.18 (0.10-0.30)<.0010.20.60.41 (0.20-0.85).0170.30.90.30 (.084-1.10).069TIA/stroke2.840.63 (0.48-0.82)<.0011.12.00.52 (0.36-0.76)<.0012.83.70.67 (0.41-1.11).12Stroke/death2.45.10.41 (0.31-0.54)<.0011.01.90.48 (0.33-0.70)<.0011.93.30.46 (0.27-0.84).011Stroke/death/MI3.05.70.45 (0.35-0.58)<.0011.42.30.54 (0.39-0.75)<.0012.33.80.51 (0.30-0.87).013MI0.60.80.73 (0.41-1.30).290.40.60.78 (0.43-1.43).430.40.60.77 (0.22-2.74).68Postoperative complications6.610.20.59 (0.49-0.70)<.0015.86.10.93 (0.77-1.13).476.76.90.95 (0.67-1.34).77CI, Confidence interval; MI, myocardial infarction; TCAR, transcarotid artery revascularization; TFAR, transfemoral artery revascularization; TIA, transient ischemic attack.Postoperative complications include any of the listed complications: reperfusion symptoms, myocardial infarction, dysrhythmia (new), congestive heart failure, access site complication, hematoma/bleeding, stenosis/occlusion, infection, pseudoaneurysm, and arteriovenous fistula.Multivariate logistic regression analysis adjusted for baseline age, ethnicity, congestive heart failure diabetes, hypertension, carotid artery disease, prior carotid endarterectomy/carotid artery stenting, smoking, race, and sex. Open table in a new tab