Transcarotid Artery Revascularization Is the Safest Carotid Artery Revascularization Option for Patients With Symptomatic Congestive Heart Failure

Abstract

Congestive heart failure (CHF) is a high-risk comorbidity for patients undergoing carotid revascularization. For patients with CHF with ejection fraction ≤30%, carotid artery stenting is preferred over carotid endarterectomy (CEA). However, there is a paucity of data regarding the best carotid revascularization method specifically for these patients. Thus, we aimed to determine the safest carotid revascularization method in patients with symptomatic CHF (sCHF). This retrospective study analyzed the Vascular Quality Initiative database for patients with sCHF with carotid stenosis undergoing CEA, transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) between December 2016 and May 2022. sCHF refers to patients with cardiac disease and physical activity limitations (New York Heart Association class II-IV). The primary outcome was in-hospital rates of stroke, death, and myocardial infarction (MI). The secondary outcomes included 30-day mortality, in-hospital stroke/death, and in-hospital stroke/death/MI. The logistic regression model was used for multivariate analysis. The study included 3909 (54.1%) CEA, 1369 (19.0%) TFCAS, and 1947 (27.0%) TCAR cases, all performed in patients with sCHF. TFCAS was associated with increased risk of 30-day mortality (adjusted odds ratio [aOR]: 2.14, 95% confidence interval [CI]: 1.41-3.24; P < .001), stroke/death (aOR: 2.57, 95% CI: 1.42-4.63); P = .002), and stroke/death/MI (aOR: 2.05, 95% CI: 1.22-3.45; P = .007) compared with CEA. However, patients with sCHF had similar outcomes with TCAR compared with CEA. Moreover, TCAR was associated with decreased odds of 30-day mortality (aOR: 0.38, 95% CI: 0.21-0.73; P = .003), stroke/death (aOR: 0.41, 95% CI: 0.20-0.85; P = .017), and stroke/death/MI (aOR: 0.45, 95% CI: 0.24-0.85; P = .014) compared with TFCAS in patients with sCHF (Table I). The subanalysis based on the symptomatic status of carotid stenosis showed persistent results only for the symptomatic cohort. In addition, TFCAS in symptomatic patients was associated with an almost threefold increase in the risk of MI (aOR: 2.73, 95% CI: 1.04-7.19; P = .041) compared with CEA, but TCAR was not. TCAR was associated with a 72% reduction in the risk of MI (aOR: 0.28, 95% CI: 0.08-0.98; P = .046) compared with TFCAS (Table II). CHF is considered a high-risk criterion for CEA and an indication for stenting. However, in this large national study, we have shown that TFCAS is associated with worse perioperative mortality, stroke/death, and stroke/death/MI compared with CEA in these patients. TCAR had similar outcomes to CEA and was superior to TFCAS in terms of 30-day mortality, stroke, stroke/death, and stroke/death/MI. The advantages of TCAR become more pronounced in symptomatic patients. Our findings suggest TCAR as the best minimally invasive method of carotid revascularization in patients with sCHF. Further research is needed to confirm our findings.Table IMultivariate analysis of all patients with symptomatic CHF stratified by carotid revascularization typeOutcomesaTFCAS vs CEATCAR vs CEATCAR vs TFCASaOR (95% CI)P valueaOR (95% CI)P valueaOR (95% CI)P value30-day mortality2.14 (1.41-3.24)<.0011.23 (0.74-2.02).4240.38 (0.21-0.73).003Stroke1.18 (0.74-1.85).4880.66 (0.41-1.08).0980.53 (0.29-0.97).039MI1.15 (0.52-2.52).7240.58 (0.33-1.00).0520.85 (0.48-1.53).594Stroke/death2.57 (1.42-4.63).0021.10 (0.63-1.92).7540.41 (0.20-0.85).017Stroke/death/MI2.05 (1.22-3.45).0070.91 (0.63-1.31).6130.45 (0.24-0.85).014ACEI, Angiotensin-converting enzyme inhibitor; aOR, adjusted odds ratio; CAD, coronary artery disease; CEA, carotid endarterectomy; CI, confidence interval; CKD, chronic kidney injury; COPD, chronic obstructive pulmonary disease; HTN, hypertension; MI, myocardial infarction; RAAS, renin-angiotensin-aldosterone system; TCAR, transcarotid artery revascularization; TFCAS, transfemoral carotid artery stenting.aAdjusting for age, sex, race, ethnicity, insurance, CAD, CKD, COPD, HTN, diabetes, smoking status, obesity, anemia, prior procedures, preoperative conditions, urgency, symptomatic status, preoperative aspirin, ACEI, P2Y12-receptor antagonist, β-blocker, anticoagulant, and RAAS inhibitor intake. Open table in a new tab Table IIMultivariate analysis of patients with symptomatic CHF with symptomatic and asymptomatic carotid stenosis stratified by carotid revascularization typeOutcomesaTFCAS vs CEATCAR vs CEATCAR vs TFCASaOR (95% CI)P valueaOR (95% CI)P valueaOR (95% CI)P valueSymptomatic carotid stenosis 30-day mortality2.26 (1.22-4.20).0101.33 (0.71-2.51).3750.32 (0.14- 0.75).008 Stroke1.47 (0.74-2.95).2740.73 (0.36-1.49).3930.44 (0.19 -1.01).054 MI2.73 (1.04- 7.19).04127 (0.08-0.97).0450.28 (0.08-0.98).046 Stroke/death3.67 (1.68-8.00).0011.10 (0.56 -2.14).7840.28 (0.13- 0.61).001 Stroke/death/MI3.63 (1.83-7.22)<.0010.90 (0.51-1.60).7270.24 (0.12-0.48)<.001Asymptomatic carotid stenosis 30-day mortality2.11 (1.16-3.84).0141.18 (0.57-2.42).6610.47 (0.21-1.07).074 Stroke1.00 (0.50-2.00).9940.64 (0.34-1.20).1660.60 (0.26-1.38).232 MI0.54 (0.19-1.52).2440.70 (0.37-1.33).2741.45 (0.65-3.22).361 Stroke/death1.93 (0.86-4.33).1231.16 (0.51-2.61).7240.58 (0.21-1.62).301 Stroke/death/MI1.23 (0.64-2.36).5340.95 (0.60-1.48).8070.88 (0.38-2.04).757ACEI, Angiotensin-converting enzyme inhibitor; aOR, adjusted odds ratio; CAD, coronary artery disease; CEA, carotid endarterectomy; CI, confidence interval; CKD, chronic kidney injury; COPD, chronic obstructive pulmonary disease; HTN, hypertension; MI, myocardial infarction; RAAS, renin-angiotensin-aldosterone system; TCAR, transcarotid artery revascularization; TFCAS, transfemoral carotid artery stenting.aAdjusting for age, sex, race, ethnicity, insurance, CAD, CKD, COPD, HTN, diabetes, smoking status, obesity, anemia, prior procedures, preoperative conditions, urgency, symptomatic status, preoperative aspirin, ACEI, P2Y12-receptor antagonist, β-blocker, anticoagulant, and RAAS inhibitor intake. 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