Outcomes After Transcarotid Artery Stenting Stratified by Preprocedural Symptom Status

Abstract

Previous studies on carotid endarterectomy and transfemoral carotid artery stenting demonstrated that perioperative outcomes differed according to prior neurologic injury severity, but these specifics remain unknown in transcarotid artery stenting (TCAR). In this study, we examined contemporary perioperative outcomes for TCAR stratified by the specific presenting symptom status. Patients who underwent TCAR between 2016 and 2021, registered within the Vascular Quality Initiative, were included. We stratified patients according to their prior symptom status as asymptomatic, formerly symptomatic (symptoms occurring >180 days before TCAR), or recently symptomatic (symptoms <180 days before TCAR). Symptoms consisted of stroke, hemispheric transient ischemic attack (TIA), and ocular TIA. Our primary outcome was the in-hospital stroke or death (stroke/death) rate, which we compared among asymptomatic, formerly symptomatic, and specific subtypes of recently symptomatic patients. Multivariable analysis was performed to adjust for demographics and comorbidities among groups. We identified 18,477 TCAR patients, of which 3417 (18%) had recent stroke, 1408 (7.6%) had recent hemispheric TIA, and 597 (3.2%) had recent ocular TIA. From the remaining patients, 1692 patients (9.2%) were formerly symptomatic, whereas 11,363 patients (62%) were asymptomatic. Patients with recent stroke had a stroke/death rate of 3.1%, which was higher than the stroke/death rate in recent ocular TIA patients (0.8%; P < .01) or patients with an asymptomatic symptom status (1.1%; P < .01). The stroke/death rate was lower in asymptomatic patients compared with recent hemispheric TIA patients (1.1% vs 2.1%; P < .01). Compared with formerly symptomatic patients, recently symptomatic patients had a higher stroke/death rate (1.7% vs 2.6%; P = .03). Furthermore, formerly symptomatic patients trended toward having a higher stroke/death rate compared with asymptomatic patients (1.7% vs 1.1%; P = .06). Following multivariable logistic regression analysis, no difference in stroke/death association was found between patients with recent stroke or recent hemispheric TIA (odds ratio [OR], 1.4; 95% confidence interval [CI], 0.9-2.1; P = .14). However, recent stroke was associated with higher stroke/death compared with recent ocular TIA (OR, 3.1; 95% CI, 1.3-7.7; P < .01) and asymptomatic status (OR, 2.7; 95% CI 2.1-3.6; P < .010) (Table I). In addition, asymptomatic status was associated with lower stroke/death compared with formerly symptomatic status (OR, 0.6; 95% CI, 0.4-0.9; P = .02) (Table II). After TCAR, patients with a recent stroke had a higher rate of in-hospital stroke/death compared with patients with recent ocular TIA. In addition, a formerly symptomatic status had a higher rate of stroke/death compared with an asymptomatic status. Therefore, specified symptom stratification can be used to improve preoperative risk assessment for TCAR.Table IAssociation between preprocedural symptom status and in-hospital stroke or death after transcarotid artery stenting (TCAR) with different reference pointsOR95% CIP valueAsymptomaticReferenceOcular TIA0.90.4-2.2.79Hemispheric TIA2.01.3-3.0<.01Stroke2.72.1-3.6<.01Asymptomatic1.10.5-2.8.79Ocular TIAReferenceHemispheric TIA2.20.9-5.8.10Stroke3.11.3-7.7.01Asymptomatic0.50.3-0.8<.01Ocular TIA0.40.2-1.2.10Hemispheric TIAReferenceStroke1.40.9-2.1.14CI, Confidence interval; OR, odds ratio; TIA, transient ischemic attack.Adjusted for age, sex, race, hypertension, current smoking status, any diabetes mellitus, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, dialysis status, and an estimated glomerular filtration rate of <30 mL/min. Open table in a new tab Table IIAssociation between formerly symptomatic, asymptomatic, and recently symptomatic status and in-hospital stroke or death after transcarotid artery stenting (TCAR)OR95% CIP valueFormerly symptomaticReferenceAsymptomatic0.60.4-0.9.02Recently symptomatic1.41.0-2.2.08CI, Confidence interval; OR, odds ratio.Adjusted for age, sex, race, hypertension, current smoking status, any diabetes mellitus, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, dialysis status, and an estimated glomerular filtration rate of <30 mL/min. Open table in a new tab