Outcomes Following Carotid Revascularization in Patients with Prior Ipsilateral Carotid Artery Stenting in the Vascular Quality Initiative

Abstract

The outcomes of carotid revascularization in patients with prior carotid artery stenting remain understudied. Prior research has not reported the outcomes after Transcarotid artery revascularization (TCAR) in patients with previous carotid artery stenting. In this study, we compared the peri-operative outcomes of TCAR, tfCAS and CEA in patients with prior ipsilateral CAS using the VQI. Using the Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA following prior ipsilateral carotid artery stenting. We included covariates such as age, race, sex, BMI, comorbidities (hypertension, diabetes, prior CAD, prior CABG/PCI, CHF, renal dysfunction, smoking, COPD, anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability-weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality and cranial nerve injury (CNI) following TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. We identified 2,137 patients undergoing revascularization following prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%) and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%,aOR:0.33[0.11-1.05]; p=0.06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%,aOR:0.80[0.16-3.98]; p=0.8). Compared with CEA, TCAR was associated with lower odds of post-operative MI (0.1% vs 14%,aOR:0.02[0.00-0.10]; p<0.001), stroke/death/MI (0.8% vs 15%,aOR:0.05[0.01-0.25]; p<0.001), and CNI (0.1% vs 3.8%,aOR:0.04[0.00-0.30]; p=0.002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1% with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (p<.001). In asymptomatic patients with prior ipsilateral carotid artery stenting, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably elevated in-hospital stroke/death rates. In line with the post-procedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.