Clinical Impact of Carotid Artery Stenosis in Patients Undergoing Trans-catheter Aortic Valve Replacement

Abstract

Introduction - Similar to surgical repair, trans-catheter aortic valve replacement (TAVR) is associated to a significant risk1 of peri-procedural and late cerebro-vascular accidents (CVA). Along with the evaluation of other predictors of CVAs, the primary endpoint of the study was to assess the clinical impact of carotid artery stenosis and staged carotid interventions for the prevention of stroke, in patients undergoing TAVR. Methods - A single-center retrospective review of a prospectively-maintained database of all TAVRs performed between 2007 and 2017 was conducted. Aortic valve procedural data and outcomes were defined according to VARC-22 criteria. Patients with concomitant carotid stenosis >70% and aortic valve stenosis were evaluated for carotid revascularization, before or after TAVR, after discussion in multidisciplinary meetings. CVAs were defined as stroke or TIA occurring within 30 days and 1 year from the procedure. Preoperative and procedural factors were evaluated for their association to CVAs using univariate analysis and multiple logistic regression. Freedom from CVAs at 1 year was evaluated using Kaplan-Meier curves. Results - During the study period, 771 TAVR procedures were performed. Mean age was 80.1±6.8 years and 46% (n=352) of patients were male. Sixty-nine (9%) patients had had pre-operative carotid stenosis>70%; 22 (2.8%) of these had bilateral stenosis and 4 (0.5%) were symptomatic. Pre-TAVR unilateral carotid revascularization was performed in 45 (5.8%) cases, with carotid endarterectomy (CEA) in 30 cases (3.8%) and with carotid artery stenting (CAS) in 15 (1.9%). TAVR device success was 96%, with a 2.5% 30-days mortality. Cardiovascular complications included 17 (2.2%) myocardial infarctions and 25 (3.2%) CVAs (22 strokes and 3 TIAs). CVA rate was higher in patients with carotid stenosis>70% at presentation, without reaching any statistical significance (4.9% vs 3.3%; P=.465). CVA rate was similar comparing patients undergoing pre-TAVR carotid revascularization and those with untreated carotid stenosis (4% vs 6.6%; P=.99); similarly patients treated with CAS had similar CVA rates compared to patients treated with CEA (6.6% vs 6.8%; P=.99). Patients with untreated bilateral carotid stenosis had no neurological complications (0% vs 3.3%; P=.99). The presence of porcelain aorta (OR 3.31, 95%CI 1.25-7.89; P=.009), valve predilatation (OR 4.17, 95%CI 1.18-26.43; P=.046) and mean arterial pressure during the procedure <90 mmHg (OR 4.18, 95%CI 1.26-13.79; P=.016) were predictors of CVAs during TAVR. Medical therapy, AF, type of valve (balloon-expandable vs self-expandable), carotid stenosis>70% and other clinical and procedural factors were not significantly associated. At the multiple logistic regression, mean procedural arterial pressure <90 mmHg was the only predictor of CVAs (OR 4.38, 95%CI 1.31-14.74; P=.014). Uni- or bilateral carotid stenosis did not show to be associated to CVAs also after adjustment for important procedural data and confounding factors (adjusted OR 1.92, 95%CI 0.09-12.38; P=.56). After 30 days from the procedure, freedom from CVA was 98.1% (95%CI 96.8-98.9) at 1 year. Conclusion - Unilateral or bilateral carotid stenosis >70% seems to have no impact on early CVAs in patients undergoing TAVR, and a staged carotid intervention may not be considered. The presence of porcelain aorta, valve predilatation, and mean procedural arterial pressure <90 mmHg are associated to peri-operative CVAs. References1Davlouros PA, Mplani VC, Koniari I, Tsigkas G, Hahalis G. Transcatheter aortic valve replacement and stroke: a comprehensive review. J Geriatr Cardiol. 2018;15:95-10.2Kappetein AP, Head SJ, Généreux P, Piazza N, van Mieghem NM, Blackstone EH, Brott TG, Cohen DJ, Cutlip DE, van Es GA, Hahn RT, Kirtane AJ, Krucoff MW, Kodali S, Mack MJ, Mehran R, Rodés-Cabau J, Vranckx P, Webb JG, Windecker S, Serruys PW, Leon MB; Valve Academic Research Consortium-2. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document. J Thorac Cardiovasc Surg. 2013;145:6-23.