Perioperative Outcomes Following Carotid Revascularization for Stroke Stratified by Modified Rankin Scale and Time of Intervention

Abstract

The relationship between modified Rankin Scale (mRS) and optimal timing of carotid revascularization in patients with prior stroke is unclear. Therefore, we compared outcomes of transfemoral carotid artery stenting (TFCAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) after prior stroke, stratified by and accounting for preoperative mRS and time-to-intervention. We identified all patients who underwent TFCAS, TCAR, and CEA after a recent stroke in the Vascular Quality Initiative in 2012 to 2020. Patients were stratified into four preoperative mRS groups (mRS 0-1, 2, 3-4, 5) and into four groups based on the days from symptom onset to carotid revascularization (≤2 days, 3-14 days, 15-90 days, 91-180 days). Primary outcome was in-hospital stroke/death rate between patients who underwent TFCAS vs TCAR vs CEA, within the different preoperative mRS and time-to-intervention groups. We identified 4415 patients who underwent TFCAS, 3138 patients who underwent TCAR, and 20,062 patients who underwent CEA. Patients were most likely to have minimal disability (mRS 0-1; 61%) and least likely to have severe disability (mRS 5; 1.5%). Patients most often underwent revascularization in 3 to 14 days (45%) and least often in 91 to 180 days (8.6%). Across all intervention methods, increasing preoperative mRS was associated with higher stroke/death (all P < .02), while increasing time-to-intervention was associated with lower stroke/death (all P < .01). After risk adjustment, undergoing TFCAS was associated with higher stroke/death compared with undergoing CEA (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.5-2.1; P < .01) or undergoing TCAR (aOR, 1.5; 95% CI, 1.2-1.9; P < .01) (Table). We observed similar stroke/death rates after CEA when compared with TCAR (aOR, 1.2; 95% CI, 1.0-1.5; P = .08). Optimal timing of carotid intervention for stroke varies with preoperative stroke severity. While we did not observe distinct stroke/death associations between CEA and TCAR, undergoing TFCAS was associated with increased stroke/death compared with undergoing CEA and TCAR. Our results indicate the effect of preoperative mRS and time to intervention on perioperative stroke/death rate after carotid revascularization, and these variables should be adjusted or controlled for in future carotid studies. The results we observed demonstrating lower associated in-hospital stroke/death rate in patients with delayed time to intervention need to be weighed against the natural history risk of recurrent events.TableUnadjusted in-hospital stroke or death (stroke/death) rates after carotid revascularization procedures for stroke and adjusted association between carotid revascularization procedure and stroke/death stratified by modified Rankin Scale (mRS) and time to interventionmRS 0-1mRS 2mRS 3-4mRS 5S/D ratesOR95% CIP valueS/D ratesOR95% CIP valueS/D ratesOR95% CIP valueS/D ratesOR95% CIP value≤2 days TFCAS7.5%2.51.5-4.1<.017.0%1.50.7-3.5.3111%1.40.9-2.3.1523%3.00.8-11.10 TCAR3.7%0.90.3-2.7.857.0%1.90.5-7.5.3714%1.60.5-5.2.41NA- CEA3.4%Ref4.7%Ref8.5%Ref8.3%Ref3-14 days TFCAS2.7%1.30.8-2.2.274.2%1.10.6-2.2.695.3%1.50.9-2.5.1226%2.30.5-9.4.26 TCAR2.9%1.30.8-2.1.305.7%1.30.7-2.5.343.9%1.00.5-1.9.990.0%- CEA1.9%Ref3.9%Ref3.8%Ref12%Ref15-90 days TFCAS2.5%2.01.1-3.5.025.0%1.90.8-4.7.174.5%1.40.6-3.4.409.1%0.50.0-14.71 TCAR2.2%1.60.9-2.7.122.9%1.00.3-2.91.05.2%1.60.7-3.6.250.0%- CEA1.3%Ref2.2%Ref3.0%Ref10%Ref91-180 days TFCAS1.1%0.70.2-3.0.613.8%1.10.2-6.8.916.7%5.41.0-28.0433%- TCAR2.4%1.00.4-2.61.00.0%-1.6%1.00.1-11.990.0%- CEA1.9%Ref4.1%Ref1.2%Ref0.0%-All mRS Cohorts and all time Cohorts CEA2.6%Ref TFCAS6.3%1.81.5-2.1<.01 CEA2.6%Ref TCAR3.2%1.21.0-1.5.08 TCAR3.2%Ref TFCAS6.3%1.51.2-1.9<.01CI, Confidence interval; OR, odds ratio; S/D, in-hospital stroke or death.Adjusted for age, race, sex, current smoking status, chronic obstructive pulmonary disease, hypertension, coronary artery disease, congestive heart failure, estimated glomerular filtration rate <30 mL/min, mRS, and time to intervention. Open table in a new tab