Optimal Method of Carotid Revascularization in Patients With Recent Myocardial Infarction

Abstract

Recent myocardial infarction (MI) represents a real challenge in patients requiring any vascular procedure. There is currently a lack of data on the effect of preoperative MI on the outcomes of carotid revascularization methodology (carotid enterectomy [CEA], transfemoral carotid artery stenting [TFCAS], or transcarotid artery revascularization [TCAR]). This study looks to identify the ideal revascularization method for patients with recent MI. Data were collected from Vascular Quality Initiative (VQI) (2016-2022) for patients with carotid stenosis in the United States and Canada with recent MI (<6 months) undergoing CEA, TFCAS, or TCAR. In-hospital outcomes after TFCAS vs CEA and TCAR vs CEA were compared. We used logistic regression models to compare the outcomes of these three procedures in patients with recent MI adjusting for potential confounders. Primary outcomes included in-hospital rates of stroke, death, and MI. Secondary outcomes included stroke/death, stroke/death/MI, postoperative hypertension, postoperative hypotension, and prolonged length of stay (>2 days). The final cohort included 1217 (54.2%) CEA, 445 (19.8%) TFCAS, and 584 (26.0%) TCAR cases. Patients undergoing CEA were more likely to have prior coronary artery bypass graft/percutaneous coronary intervention and to use anticoagulant. Patients undergoing TFCAS were more likely to be symptomatic, have prior congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease, and undergo urgent operations. Patients undergoing TCAR were more likely to have higher rates of aspirin class IV-V, protamine, and P2Y12 inhibitor use. In the univariate analysis, CEA was associated with a lower rate of ipsilateral stroke (P = .079) and death (P = .002) (see Table I for secondary outcomes). After adjusting for confounders, TFCAS was associated with increased risk of stroke/death (adjusted odds ratio [aOR]: 2.69; 95% CI: 1.36-5.35; P = .005) and stroke/death/MI (aOR: 1.67; 95% CI: 1.07-2.60; P = .025) compared with CEA. However, TCAR had similar outcomes to CEA (Table II). Both TFCAS and TCAR were associated with increased risk of postoperative hypotension (aOR: 1.71; 95% CI: 1.24-2.36; P = .001 and aOR: 1.82; 95% CI: 1.37-2.41; P ≤ .001, respectively) compared with CEA. However, TCAR was associated with a decreased risk of postoperative hypertension (aOR: 0.55; 95% CI: 0.39-0.75; P ≤ .001) compared with CEA (Table II). Although recent MI has been established as a high-risk criterion for CEA and an approved indication for TFCAS, this study showed that CEA is safer in this population with lower risk of stroke/death and stroke/death/MI compared with TFCAS. TCAR had similar stroke/death/MI outcomes to CEA in patients with recent MI. Further prospective studies are needed to confirm our findings.Table IPostoperative outcomes of carotid enterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) in patients with recent myocardial infarction (MI)In-hospitalUnivariableCEATFCASTCARNo. (%)No. (%)No. (%)P valueStroke27 (2.22)15 (3.40)19 (3.26).277Ipsilateral Stroke19 (1.56)14 (3.17)16 (2.74).079Death14 (1.15)17 (3.82)13 (2.23).002MI28 (2.30)8 (1.80)8 (1.37).398Stroke/death40 (3.29)29 (6.56)28 (4.79).012Stroke/death/MI60 (4.93)36 (8.14)34 (5.82).046Postoperative hypertension278 (22.84)50 (11.26)80 (13.72)<.001Postoperative hypotension187 (15.37)112 (25.23)149 (25.56)<.001Prolonged length of stay565 (46.43)233 (52.36)268 (45.89).068 Open table in a new tab Table IIPostoperative outcomes of transfemoral carotid artery stenting (TFCAS) vs carotid enterectomy (CEA) and transcarotid artery revascularization (TCAR) vs CEA in patients with preoperative myocardial infarction (MI) after adjusting for confounding factors (reference = CEA)In-hospitalMultivariableaTFCAS vs CEATCAR vs CEAOR (95% CI)P valueOR (95% CI)P valueStroke1.30 (0.69-2.47).4131.42 (0.77-2.62).260Ipsilateral stroke1.49 (0.69-3.23).3081.90 (0.87-4.11).105Death2.42 (1.00-5.89).0512.21 (0.89-5.46).086MI0.84 (0.37-1.88).6640.57 (0.24-1.34).197Stroke/death2.69 (1.36-5.35).0051.45 (0.84-2.51).185Stroke/death/MI1.67 (1.07-2.60).0251.10 (0.68-1.78).701Postoperative hypertension0.66 (0.41-1.04).0730.55 (0.39-0.75)<.001Postoperative hypotension1.71 (1.24-2.36).0011.82 (1.37-2.41)<.001Prolonged length of stay (>2 days)1.12 (0.81-1.55).4810.96 (0.72-1.27).761ASA, Aspirin; CABG, coronary artery bypass graft; CHF, congestive heart failure; CI, confidence interval; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention.aMultivariate analysis adjusted for the following confounders: age, gender, race, ethnicity, obesity, symptomatic status, diabetes, hypertension, CHF, COPD, CKD, ASA class, prior occlusions, CABG/PCI, procedure urgency, smoking, and use of preoperative medications. Open table in a new tab