Carotid Revascularization Procedures Research Articles

Outcomes of Carotid Artery Stenting and Endarterectomy in Patients with Prior Contralateral Carotid Revascularization

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are available treatment options for stroke prevention in individuals with severe carotid stenosis. This study aims to compare the early postoperative outcomes in patients who underwent CEA or CAS after prior contralateral carotid revascularization. We conducted a retrospective review of the Society of Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database, identifying patients who had prior carotid artery revascularization followed by a contralateral CEA or CAS between 2017 and 2023. Based on the sequence of the procedures performed, patients were categorized into four groups: 1) patients who had a prior unilateral CEA followed by a contralateral CEA (CEA-CEA); 2) patients who had a prior unilateral CAS followed by a contralateral CEA (CAS-CEA); 3) patients had a prior unilateral CAS followed by a contralateral CAS (CAS-CAS); and 4) patients had a prior unilateral CEA followed by a contralateral CAS (CEA-CAS). Univariate analysis (Pearson χ 2, Wilcoxon rank sum test) and multivariate logistic regression were employed to assess length of stay, rates of in-hospital stroke, myocardial infarction, new-onset arrhythmia, and 30-day mortality. A total of 20,761 patients with a history of prior unilateral carotid revascularization procedures were identified, of which 12,788 underwent contralateral CEA and another 7,973 underwent contralateral CAS. Compared to the CAS-CAS group, patients who underwent CEA followed by contralateral CAS (CEA-CAS group) were associated with higher rates of postoperative in-hospital stroke (1.8% vs. 1%, P = 0.003), new-onset arrhythmia (2% vs. 1.2%, P=0.006), and 30-day mortality (1.3% vs. 0.8%, P = 0.04). On multivariate analysis, preoperative use of statins and beta-blockers was associated with lower odds of in-hospital stroke (OR 0.42; 95% confidence interval [CI] 0.29 - 0.69; P = 0.0002) and new-onset arrhythmia (OR 0.62; 95% CI 0.49 - 0.9; P = 0.01), respectively, after CAS. There were no significant differences in outcomes for CEA-CEA and CAS-CEA groups. Patients with prior CEA undergoing contralateral CAS had higher rates of in-hospital stroke, new-onset arrhythmia, and 30-day mortality. Beta-blockers may reduce postoperative arrhythmia rates in these patients, and established regimens should not be discontinued in the perioperative period; however, further prospective studies are needed to confirm this finding. Optimized medical treatment and appropriate imaging follow-up remain crucial for improvement outcomes.

Postoperative outcomes in patients with anemia undergoing carotid revascularization

BackgroundPreoperative anemia is associated with worse postoperative morbidity and mortality after major vascular procedures. Limited research has examined the optimal method of carotid revascularization in patients with anemia. Therefore, we aim to compare the postoperative outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among patients with anemia. Study designThis is a retrospective review of patients with anemia undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016 and 2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACE). Logistic regression models were used for multivariate analyses. ResultsOur study included 40,383 CEA (59.3%), 9159 TFCAS (13.5%), and 18,555 TCAR (27.3%) cases in patients with anemia. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with a decreased 30-day mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.37-0.59; P < .001), in-hospital MACE (aOR, 0.58; 95% CI, 0.46-0.75; P < .001) compared with TFCAS. Additionally, TCAR was associated with a 20% decrease in the risk of 30-day mortality (aOR, 0.80; 95% CI, 0.65-0.98; P = .03) and a similar risk of in-hospital MACE (aOR, 0.86; 95% CI, 0.77-1.01; P = .07) compared with CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR, 2; 95% CI, 1.5-2.68; P < .001) and in-hospital MACE (aOR, 1.7; 95% CI, 1.4-2; P < .001) compared with CEA. ConclusionsIn this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS was associated with a high risk of 30-day mortality and in-hospital MACE compared with CEA and TCAR in patients with anemia. TCAR was associated with a lower risk of 30-day mortality compared with CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in patients with anemia.

Outcomes of Carotid Artery Revascularization Procedures in Patients with High-grade Bilateral Stenosis

Outcomes of Carotid Artery Revascularization Procedures in Patients with High-grade Bilateral Stenosis

The effect of controlled vs uncontrolled hypertension on outcomes of carotid revascularization procedures

BackgroundHypertension (HTN) has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled HTN (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population. MethodsWe studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from the Vascular Quality Initiative. Patients were stratified into two groups: those with cHTN and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure of <130/80 mm Hg. Patients with uHTN had a blood pressure of ≥130/80 mm Hg. Our primary outcomes were in-hospital stroke, death, myocardial infarction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension or HTN, reperfusion syndrome, prolonged length of stay (LOS) (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis. ResultsA total of 34,653 CEA (uHTN, 11,347 [32.7%]), 8199 TFCAS (uHTN, 2307 [28.1%]), and 17,309 TCAR (uHTN, 4990 [28.8%]) patients were included in this study. There was no significant difference in age between patients with cHTN and patients with uHTN for each carotid revascularization procedure. However, compared with patients with cHTN, patients with uHTN had significantly more comorbidities. uHTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR], 1.56; 95% confidence interval [CI], 1.30-1.87; P < .001), TFCAS (aOR, 1.59; 95% CI, 1.21-2.08; P < .001), and TCAR (aOR, 1.39; 95% CI, 1.12-1.73; P = .003) compared with cHTN. Additionally, uHTN was associated with a prolonged LOS after all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR, 1.82; 95% CI, 1.39-2.37; P < .001), in-hospital death (aOR, 3.73; 95% CI, 2.25-6.19; P < .001), reperfusion syndrome (aOR, 6.24; 95% CI, 3.57-10.93; P < .001), and extended LOS (aOR, 1.87; 95% CI, 1.51-2.32; P < .001) compared with CEA. There was no statistically significant difference between the outcomes of TCAR compared with CEA. ConclusionsThe results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with cHTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. Additionally, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be safer interventions. Patients with uTHN with symptomatic carotid disease treated with CEA or TCAR have better outcomes compared with those treated with TFCAS.

15-year Trends in Age and Sex Specific Utilization of Carotid Revascularization Procedures in the United States (P3-5.002)

15-year Trends in Age and Sex Specific Utilization of Carotid Revascularization Procedures in the United States (P3-5.002)

Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report.

Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program. The benefits of selective screening for AsxCS include early recognition of AsxCS allowing timely initiation of preventive measures to reduce future myocardial infarction (MI), stroke, cardiac death and cardiovascular (CV) event rates. Mass screening programs for AsxCS are neither clinically effective nor cost-effective. Nevertheless, targeted screening of populations at high risk for AsxCS provides an opportunity to identify these individuals earlier rather than later and to initiate a number of lifestyle measures, risk factor modifications, and intensive medical therapy in order to prevent future strokes and CV events. For patients at 'higher risk of stroke' on best medical treatment, a prophylactic carotid intervention may be considered.

Abstract 49: 15-Year Trends in Age and Sex-Specific Utilization of Carotid Revascularization Procedures in the United States

Background: In July 2023, the Center for Medicare and Medicaid Services (CMS) proposed broader coverage for carotid artery stenting (CAS) for patients with symptomatic (Sx) and asymptomatic carotid disease (Asx) in the United States (US) Objectives: This study provides a 15-year snapshot of current CAS and carotid endarterectomy (CEA) use in various age and sex groups of the US. Methods: We identified all Sx and Asx CAS and CEA admissions in adults (≥18 years) from the 2006-2020 National Inpatient Sample using International Classification of Diseases codes. We calculated the age and sex-specific proportions of revascularizations that were CAS and combined annual CAS/CEA counts with census data to determine annual utilization rate per 100,000 population. We used Joinpoint regression to estimate annualized percentage change (APC) in usage over time. Results: Of 1,591,651 weighted procedures over the study period, 30% were done in 60-69 year olds and 20% in ≥80 year olds. This age distribution was constant over time. 15.1% of all procedures were CAS but this proportion doubled over time such that in 2020, 29.6% of all procedures were CAS. CAS proportion increased in all age groups including those &gt;70 years and in women, even after excluding patients with tandem occlusions (Figure 1). 22.5% of CAS and 11.7% of CEA were done in Sx patients but this proportion increased over time in both CAS and CEA (p-trend &lt;0.001). Annual usage of CEA declined from 51.6 to 22.5 cases/100,000 population in both sexes combined (APC -5.4%, 95%CI -6.0 to -4.8), while CAS use declined from 2006-2016 but increased significantly over 2016-2020 in both men (APC 16.5%, 95%CI 10.0 to 23.3) and women (APC 15.2%, 95%CI 10.2 to 20.4) (Figure 1). Conclusion: Despite uncertain benefit in selected age and sex groups including those &gt; 70years, CAS use has continued to increase in all age and sex groups and now accounts for one-third of carotid revascularizations . With the CMS change CAS use could increase further.

Preoperative Ocular Symptoms Predict Acute Glaucoma After Carotid Revascularization: An Analysis of Combined Single-Center Data and a Systematic Review

BackgroundAcute glaucoma is a potential complication of carotid revascularization procedures such as endarterectomy or stenting. Although preoperative ocular hypoperfusion may predispose patients to postoperative glaucoma, the details of this complication have not been clarified. MethodsWe retrospectively reviewed the medical records of consecutive patients who underwent carotid revascularization at our institution from January 2019 to December 2022. These patients were divided into glaucoma and non-glaucoma groups. Given the rarity of the event, a systematic literature review was performed to additionally include data from patients who developed acute glaucoma after carotid revascularization. Multivariate logistic regression was performed to identify the risk factors for acute glaucoma. ResultsThirty-five cases, including two from our institution, were included in the glaucoma group, and 130 were included in the non-glaucoma group. Most cases (79%) occurred within five days postoperatively. Multivariate analysis revealed that preoperative ocular symptoms were significantly associated with the development of postoperative glaucoma (odds ratio, 361.06; 95% confidence interval, 34.09–3824.27; P<0.001). Preoperative neovascularization at the iris or anterior chamber angle, indicating severe ocular hypoperfusion, was found in 84% of patients with glaucoma. Permanent visual loss occurred in 41% of patients. The incidence of postoperative glaucoma at our institution was 1.5% (2/132). The positive predictive value of preoperative ocular symptoms for postoperative glaucoma was 0.25 (95% confidence interval, 0.18–0.32). ConclusionsThis study was the first to clarify the risk factors and characteristics of acute glaucoma after carotid revascularization.

Socioeconomic status as a predictor of post-operative mortality and outcomes in carotid artery stenting vs. carotid endarterectomy.

The association between low socioeconomic status (SES) and worse surgical outcomes has become an emerging area of interest. Literature has demonstrated that carotid artery stenting (CAS) poses greater risk of postoperative complications, particularly stroke, than carotid endarterectomy (CEA). This study aims to compare the impact of low SES on patients undergoing CAS vs. CEA. The National Inpatient Sample (NIS) was queried for patients undergoing CAS and CEA from 2010 to 2015. Patients were stratified by highest and lowest median income quartiles by zip code and compared through demographics, hospital characteristics, and comorbidities defined by the Charlson Comorbidity Index (CCI). Primary outcome was in-hospital mortality. Secondary outcomes included acute kidney injury (AKI), post-operative stroke, sepsis, and bleeding requiring reoperation.Multivariable logistic regression was used to determine the effect of SES on outcomes. Five thousand four hundred twenty-five patients underwent CAS (Low SES: 3,516 (64.8%); High SES: 1,909 (35.2%) and 38,399 patients underwent CEA (Low SES: 22,852 (59.5%); High SES: 15,547 (40.5%). Low SES was a significant independent predictor of mortality [OR = 2.07 (1.25-3.53); p = 0.005] for CEA patients, but not for CAS patients [OR = 1.21 (CI 0.51-2.30); p = 0.68]. Stroke was strongly associated with low SES, CEA patients (Low SES = 1.5% vs. High SES = 1.2%; p = 0.03), while bleeding was with high SES, CAS patients (Low SES = 5.3% vs. High SES = 7.1%; p = 0.01). CCI was a strong predictor of mortality for both procedures [CAS: OR1.45 (1.17-1.80); p < 0.001. CEA: OR1.60 (1.45-1.77); p < 0.001]. Advanced age was a predictor of mortality post-CEA [OR = 1.03 (1.01-1.06); p = 0.01]. While not statistically significant, advanced age and increased mortality trended towards a positive association in CAS [OR = 1.05 (1.00-1.10); p = 0.05]. Low SES is a significant independent predictor of post-operative mortality in patients who underwent CEA, but not CAS. CEA is also associated with higher incidence of stroke in low SES patients. Findings demonstrate the impact of SES on outcomes for patients undergoing carotid revascularization procedures. Prospective studies are warranted to further evaluate this disparity.

Abstract 17231: Importance of Intra Plaque Hemorrhage During Carotid Artery Revascularization

Introduction: The American Heart Association currently estimates that every 3 minutes a person dies from a stroke. Carotid artery stenosis, a major risk factor for new and recurrent strokes, can be treated with carotid artery revascularization. Vascular emboli released during this procedure are non-invasively detected by transcranial doppler (TCD) ultrasound as micro embolic signals (MES). In this study we aim to show the relationship between carotid plaque characteristics and MES rates that were detected by TCD-monitoring throughout the stages of the carotid artery revascularization procedures. Methods: Before elective carotid revascularization 30 patients (mean age 72±8 years; 16 males, 14 females) underwent 3-T MRI. After localization of the carotid bifurcation using phase contrast imaging, Time-of-Flight, 3D T1 weighting, transverse T1 and T2 weightings and proton density sequences were acquired. The different plaque components: lipid core, intraplaque hemorrhage, calcification and the characterization of the fibrous cap were assessed. While 20 patients underwent carotid endarterectomy (CEA), 10 patients had carotid artery stenting (CAS). CES was divided into 9 stages: 1- Pre-procedure, 2- Dissection, 3- IC clamp, 4- Shunt placement, 5- Shunt open, 6- Endarterectomy, 7- Clamped, 8- IC opened, 9- Post-procedure. Similarly, CAS was divided into 9 stages: 1- Pre-procedure, 2- Arch-carotid angiography, 3- Wire insertion, 4- Filter deployment, 5- Pre-dilation, 6- Stent deployment, 7- Post-dilation, 8- Final angiography, 9- Post-procedure. Patients were monitored continuously with TCD to detect pre-procedural, intra-procedural and post-procedural MES rates. Results: Intraplaque hemorrhage was observed in 18 patients (60%). Patients with intra plaque hemorrhage had more MES during carotid artery dissection/arch-carotid angiography (p=0.028) and IC clamping/wire insertion (p=0.009) compared to patients without intra plaque hemorrhage in the pre-procedural stage. Conclusions: Carotid plaques with intra plaque hemorrhage is associated with higher MES during carotid artery revascularization procedures.

Abstract 11771: Validity of an Administrative Claims-Based Measure of Low-Value Carotid Revascularization

Introduction: Low value care is defined as care where harms or costs outweigh benefits. Researchers, payers, and policymakers commonly use administrative claims data to identify low-value care, but the validity of many claims-based algorithms has not been assessed. Research Question: What is the validity of a commonly-used claims-based algorithm to identify low-value carotid artery revascularization (CAR) procedures, compared to a reference standard of chart review? Methods: This was a retrospective cohort study of Medicare fee-for-service beneficiaries attributed to a large accountable care organization. We used administrative claims data linked to electronic health record data and identified all CAR procedures (endarterectomy or stenting) from 01/01/2020-12/31/2021. We excluded patients without claims history in the year prior to CAR. Using methods previously described by policymakers and researchers, we classified CAR as low-value by claims if patients did not have diagnosis codes for stroke, transient ischemic attack, or other neurologic symptoms such as vision changes or hemiplegia in the year prior to CAR. We then reviewed linked electronic health records to determine if cases were misclassified by the claims-based measure. Per recent guidelines, we classified CAR as low-value by chart review if it was performed in patients with less than 50% symptomatic stenosis or greater than 80% asymptomatic stenosis. Results: A total of 127 CAR cases (mean age 77 years; 63% men; 87% white) with complete electronic health record data were identified, and 48 (38%) were classified as low-value by the claims-based algorithm. Only 11 of the 48 cases classified as low-value by claims were confirmed to be low-value by chart review. The positive predictive value of the claims-based algorithm was 23%. Conclusions: A commonly-used claims-based measure to identify low-value CAR procedures had poor accuracy with a positive predictive value of 23%. Using administrative claims to identify low-value CAR procedures might overestimate the number of procedures considered to be low-value. This has implications for the current system of quality reporting, particularly when quality is tied to financial incentives.

Abstract 17178: Rates of Micro Embolic Signals at Different Stages of Carotid Artery Revascularization

Background: The American Heart Association currently estimates that over 160,000 people die every year due to new or recurrent strokes, many from carotid artery stenosis. This association has led to increased use of carotid revascularization procedures such as carotid endarterectomy (CEA) and carotid artery stenting (CAS). In this study we aim to describe the different rates of micro embolic signals (MES) at different stages of carotid artery revascularization. Methods: Before elective carotid revascularization 57 patients (mean age 72±8 years; 15 males, 21 females) underwent 3-T MRI. After localization of the carotid bifurcation using phase contrast imaging, Time-of-Flight, 3D T1 weighting, transverse T1 and T2 weightings and proton density sequences were acquired. The different plaque components: lipid core, intraplaque hemorrhage, calcification and the characterization of the fibrous cap were assessed. While 34 patients underwent CEA, 20 patients had CAS. CES was divided into 9 stages: 1- Pre-procedure, 2- Dissection, 3- IC clamp, 4- Shunt placement, 5- Shunt open, 6- Endarterectomy, 7- Clamped, 8- IC opened, 9- Post-procedure. Similarly, CAS was divided into 9 stages: 1- Pre-procedure, 2- Arch-carotid angiography, 3- Wire insertion, 4- Filter deployment, 5- Pre-dilation, 6- Stent deployment, 7- Post-dilation, 8- Final angiography, 9- Post-procedure. Patients were monitored continuously with transcranial doppler (TCD) to detect pre-procedural, intra-procedural and post-procedural MES rates. Results: MES was detected in 20 (87%) patients undergoing CAS compared to 18 (53%) patients undergoing CES during the IC Clamp/Wire Insertion stage (p=0.004). Greater mean micro embolic signals were also found in symptomatic patients undergoing CAS than in asymptomatic patients during arch-carotid angiography (10.8 vs 2.4, p= 0.022), post-dilation (3.1 vs 1.1, p=0.047), and post-procedure (4.8 vs 1.3, p=0.044). Conclusion: MES is increased during the wire insertion stage of CAS in addition to post-dilation and post-procedure stages. Also, the finding of increased MES during arch-carotid angiography suggests that less invasive alternatives to diagnostic angiography should be considered in symptomatic patients.

Propensity-Score Matched Analysis of Three Years Survival of Trans Carotid Artery Revascularization Versus Carotid Endarterectomy in the Vascular Quality Initiative Medicare-Linked Database.

Carotid endarterectomy (CEA) remains the gold standard procedure for carotid revascularization. Transfemoral carotid artery stenting (TFCAS) was introduced as a minimally invasive alternative procedure in patients who are at high risk for surgery. However, TFCAS was associated with an increased risk of stroke and death compared to CEA. Transcarotid artery revascularization (TCAR) has outperformed TFCAS in several prior studies and has shown similar perioperative and 1-year outcomes compared with CEA. We aimed to compare the 1-year and 3-year outcomes of TCAR versus CEA in the Vascular Quality Initiative (VQI)-Medicare-Linked [Vascular Implant Surveillance and Interventional Outcomes Network (VISION)] database. The VISION database was queried for all patients undergoing CEA and TCAR between September 2016 to December 2019. The primary outcome was 1-year and 3-year survival. One-to-one propensity-score matching (PSM) without replacement was used to produce 2 well-matched cohorts. Kaplan-Meier estimates, and Cox regression was used for analyses. Exploratory analyses compared stroke rates using claims-based algorithms for comparison. A total of 43,714 patients underwent CEA and 8089 patients underwent TCAR during the study period. Patients in the TCAR cohort were older and were more likely to have severe comorbidities. PSM produced two well-matched cohorts of 7351 pairs of TCAR and CEA. In the matched cohorts, there were no differences in 1-year death [hazard ratio (HR)=1.13; 95% CI, 0.99-1.30; P =0.065]. At 3-years, TCAR was associated with slight increased risk of death (HR=1.16; 95% CI, 1.04-1.30; P =0.008). When stratifying by initial symptomatic presentation, the increased 3-year death associated with TCAR persisted only in symptomatic patients (HR=1.33; 95% CI, 1.08-1.63; P =0.008). Exploratory analyses of postoperative stroke rates using administrative sources suggested that validated measures of claims-based stroke ascertainment are necessary. In this large multi-institutional PSM analysis with robust Medicare-linked follow-up for survival analysis, the rate of death at 1 year was similar in TCAR and CEA regardless of symptomatic status. The slight increase in the risk of 3-year death in symptomatic patients undergoing TCAR is likely confounded by more severe comorbidities despite matching. A randomized controlled trial comparing TCAR to CEA is necessary to further determine the role of TCAR in standard-risk patients requiring carotid revascularization.

The Effect of Controlled Versus Uncontrolled Hypertension on Outcomes in Carotid Revascularization Procedures

Hypertension has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled hypertension (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population. We studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from Vascular Quality Initiative. Patients were stratified into two groups: those with controlled HTN (cHTN) and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure <130/80. Patients with uHTN had a blood pressure ≥130/80. Our primary outcomes were in-hospital stroke, in-hospital death, in-hospital myocardial infraction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension/hypertension, prolonged length of stay (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis. A total of 34,653 CEA (uHTN = 11,347, 32.7%), 8199 TFCAS (uHTN = 2307, 28.1%), and 17,309 TCAR (uHTN = 4990, 28.8%) patients were included in this study. There was no significant difference in age between patients with cHTN and uHTN for each carotid revascularization procedure. However, compared with cHTN, patients with uncontrolled HTN had significantly more comorbidities. Uncontrolled HTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR] = 1.55, 95% CI: 1.30-1.86; P < .001), TFCAS (aOR = 1.62, 95% CI: 1.24-2.11; P < .001), and TCAR (aOR = 1.39, 95% CI: 1.11-1.72; P = .004) compared with controlled HTN (Table I). In addition, uHTN was associated with prolonged length of stay following all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR = 1.82, 95% CI: 1.39-2.37; P < .001), in-hospital death (aOR = 3.73, 95% CI: 2.25-6.19; P < .001), and extended length of stay (aOR = 1.87, 95% CI: 1.51-2.32; P < .001) compared with CEA (Table II). There was no statistically significant difference between these outcomes for TCAR compared with CEA. The results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with HTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. In addition, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be the safer interventions. Further studies are needed to address the challenges of better HTN control in symptomatic urgent carotid revascularization procedures.Table IMultivariate logistic regression analysis of postoperative outcomes carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery revascularization (TCAR), stratified by status of hypertension (reference = controlled hypertension)OutcomeCEATF-CASTCARaOR (95% CI)P valueaOR (95% CI)P valueaOR (95% CI)P valueStroke1.84 (1.46-2.30)<.0011.95 (1.45-2.63)<.0011.32 (1.00-1.73).051In-hospital death1.69 (1.17-2.47).0060.98 (0.65-1.49).9221.24 (0.78-1.96).36530-day mortality1.32 (1.00-1.75).0500.93 (0.62-1.41).7401.47 (1.03-2.11).036MI1.26 (0.91-1.74).1631.68 (0.74-3.79).2121.53 (0.94-2.48).088Stroke or death1.69 (1.37-2.08)<.0011.51 (1.14-2.01).0041.31 (1.02-1.68).037Stroke, death, or MI1.55 (1.30-1.86)<.0011.62 (1.24-2.11)<.0011.39 (1.11-1.72).004Postoperative hypertension1.64 (1.39-1.95)<.0011.96 (1.58-2.44)<.0011.67 (1.38-2.01)<.001Postoperative hypotension0.83 (0.69-1.00).0541.14 (0.95-1.36).1650.95 (0.82-1.10).491Extended LOS (>1 day)1.30 (1.18-1.45)<.0011.59 (1.34-1.90)<.0011.14 (1.01-1.29).029aOR, Adjusted odds ratio; CI, confidence interval; COPD, chronic obstructive pulmonary disease; LOS, length of stay; MI, myocardial infraction.All variables adjusted for background characteristics (age, race, and ethnicity), insurance, preoperative medications (aspirin, P2Y12 receptor antagonist, statin, and β-blocker), anesthesia type, urgency, smoking status, symptomatic status, and comorbidities (congestive heart failure, coronary artery disease, diabetes, COPD, and chronic kidney disease). Open table in a new tab Table IIMultivariate analysis of all patients with uncontrolled hypertension stratified by carotid revascularization type (reference = carotid endarterectomy [CEA])OutcomeTF-CASTCARaORP valueaORP valueStroke1.82 (1.39-2.37)<.0011.07 (0.79-1.45).648In-hospital death3.73 (2.25-6.19)<.0010.88 (0.54-1.43).59430-day mortality3.10 (2.01-4.76)<.0010.98 (0.68-1.43).932MI0.81 (0.41-1.59).5370.83 (0.52-1.32).433Stroke or death1.97 (1.51-2.58)<.0011.10 (0.83-1.46).501Stroke, death, or MI1.73 (1.35-2.23)<.0011.06 (0.83-1.35).654Postoperative hypertension0.76 (0.59-0.99).0430.63 (0.52-0.77)<.001Postoperative hypotension2.48 (1.94-3.18)<.0012.12 (1.77-2.55)<.001Extended LOS (>1 day)1.87 (1.51-2.32)<.0010.92 (0.80-1.05).216aOR, Adjusted odds ratio; CI, confidence interval; COPD, chronic obstructive pulmonary disease; LOS, length of stay; MI, myocardial infraction; TCAR, transcarotid artery revascularization; TF-CAS, transfemoral carotid artery stenting.All variables adjusted for background characteristics (age, race, and ethnicity), insurance, preoperative medications (aspirin, P2Y12 receptor antagonist, statin, and β-blocker), anesthesia type, urgency, smoking status, symptomatic status, and comorbidities (congestive heart failure, coronary artery disease, diabetes, COPD, and chronic kidney disease). 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470 Robotic Transcranial Doppler With Artificial Intelligence for Real-Time Intraoperative Neuromonitoring During Endovascular Carotid Revascularization – A Novel and Autonomous Neuromonitoring Tool

INTRODUCTION: Real-time intraoperative neuromonitoring is crucial to account for cerebral blood flow and embolic protection offered by proximal and distal cerebral protection devices during carotid revascularization procedures. METHODS: All patients diagnosed with high-grade carotid stenosis were prospectively enrolled between October 2021 thru February 2022. The TCD Robot head-brace system was used to secure the patients head, and the robot calibrated to automatically identify ipsilateral MCA or the terminal ICA. Patient demographics and procedural characteristics relevant to the robotic system such as signal strength, time to find signal, intracranial depth of the relevant vessel, cerebral waveform, and emboli count were recorded for the 4 critical phases: i- Access to crossing the lesion, ii- Filter and balloon deployment, iii- Stent placement and implantation, and iv- Removal of delivery system. RESULTS: Eight patients were included in our study (6 males [75%]; mean age 71.5 ± 3.9). Six out of 8 patients were symptomatic with a mean diameter stenosis of 83.5 ± 4.1. Average time taken to find a stable signal was 62 seconds (Range: 10-122). Terminal ICA was the vessel identified in all cases with a mean depth of 64mm (Range: 59-71). Flow arrest was demonstrated in all cases with flow reversal demonstrated in 2. Mean duration for the TCD Robotic surveillance was 23.6 ± 0.9 minutes with an average of 117 distal emboli (Range: 45-143) recorded by the device. Linear regression model identified stent placement and implantation as statistically significant (P = 0.0419) contributor to the final emboli count. CONCLUSIONS: To our knowledge, this is the first case series of real-time comprehensive neuromonitoring using a Robotic Transcranial Doppler system with Artificial Intelligence demonstrating various cerebral blood flow parameters including flow arrest and distal embolic incidence intra-operatively.

Role of Transcarotid Artery Revascularization (TCAR) as a Carotid Revascularization Option

Transcarotid artery revascularization (TCAR) is a hybrid carotid revascularization procedure in which carotid stenting is accomplished by making an incision at the base of the neck & surgically exposing the common carotid artery. The evidence base for TCAR safety & efficacy comes from PROOF, ROADSTER, & ROADSTER 2 studies. The Society for Vascular Surgery guidelines for the treatment of carotid artery disease (2022) opine TCAR to be at least equivalent to Carotid Endarterectomy (CEA) in terms of safety & efficacy, with some potential improvements. In comparison with Transfemoral Carotid Artery Stenting (TF-CAS), the overall data demonstrates better outcomes with TCAR. In high-risk subjects like elderly more symptomatic patients with higher concurrent medical comorbidities, TCAR in fact appears to be preferable to both CEA & TF-CAS. Whereas this technique appears safe in the short-term, long-term vessel patency requires prospective follow-up studies.

Abstract WP134: Long-Term Spontaneous Recanalization Rates Of Symptomatic Cervical Carotid Artery Occlusions

Background: Long-term rates of spontaneous recanalization of a previously acutely symptomatic cervical internal carotid artery occlusion (ICAO) have not been well characterized. The purpose of this study was to determine the rate of ICAO recanalization after index transient ischemic attack (TIA)/stroke in patients with serial vessel imaging, and the clinical factors associated with recanalization. Methods: This was a single-center, retrospective analysis from 2012-2020 of patients presenting with TIA/stroke due to an acute cervical ICAO. Patients were included if follow-up neck vessel imaging (CTA, MRA or ultrasound) was performed after index TIA/stroke. Recanalization was classified as the presence of continuous flow within the cervical carotid artery on repeat imaging. Patients were excluded if they received catheterization of the occluded artery during index admission or if the occlusion was previously documented (i.e., chronic). Results: Fifty-five patients were included in this study (mean age 61 ± 12 years, 27% female). The most common etiology for cervical ICAO was atherosclerosis (71%), followed by dissection (22%). Twelve patients (22%) demonstrated recanalization on follow-up imaging at a median of 125 days from index TIA/stroke (range 2-1072 days). Three patients with recanalization underwent carotid revascularization with endarterectomy or stenting. The administration of intravenous alteplase during index stroke admission was associated with recanalization (p=0.008). However, discharge antithrombotic regimen (antiplatelet or anticoagulation) or the etiology of the occlusion were not associated with recanalization (p=0.48 and p=0.73, respectively). There was no difference in 6-month recurrent TIA/stroke rates between those with recanalization (1 patient, 8.3%) and those without recanalization (4 patients, 9.3%), p=1.0. Conclusion: Cervical ICAO recanalization occurred in 12 (22%) patients in our cohort at follow-up and allowed for carotid revascularization procedures in 3 (25%) of these patients. Outpatient follow-up cervical vessel imaging should be considered after symptomatic cervical ICAO, as identifying spontaneous recanalization can alter management.

Abstract WMP78: Predictors Of Memory And Carotid Intervention-related Memory Changes

Introduction: Carotid atherosclerosis is the culprit of stroke and dementia. It has been linked to cognitive impairment in cerebrovascular diseases . A bulk of evidence suggests that carotid interventions improve cognitive functions in appropriately selected patients. We aim to investigate the factors that modulate changes in episodic memory following carotid recanalization procedures. Methods: A total of 170 subjects undergoing carotid revascularization procedures were recruited prospectively. Neuropsychometric testing was performed preoperatively, and at 1-,6-, and 12-month postoperatively. Rey Auditory Verbal Learning Test (RAVLT) was used to assess episodic memory. Changes in RAVLT sum scores at individual time points were compared to the baseline. Linear and logistic regression models were fitted to predict RAVLT sum baseline score, and postop changes at each time point compared to preop, respectively. Univariate and multivariate analyses (after adjusting for risk factors and patient demographics) were performed and variables with p &lt;0.25 were included in the multivariable analysis. Results: At baseline, having a prior stroke, and being older than 80 years of age were independent predictors of a low preop RAVLT sum score (p=0.001 and p=0.001 respectively). Interestingly, a low preop RAVLT sum score is the only independent predictor of post-intervention cognitive improvement at all three time points compared to preop (P&lt;0.01). CEA and Age &lt;80 years predicted short-term improvement at 1 and 6 months postop. Conversely, carotid artery stenting (CAS) is an independent predictor of verbal memory decline at 1-month post-intervention (p=0.039), while being older than 80 years of age predicted the decline at 1-month (p= 0.046) and 6-month (p= 0.043) postoperatively. Conclusion: Younger patients with severe atherosclerotic carotid disease and low baseline episodic memory scores benefit most from carotid intervention, specifically CEA, whereas age ≥80 years predicts poor baseline memory score and worse intervention-related memory change. Further studies with larger sample sizes are necessary to confirm the characteristics of patients with carotid occlusive disease who could benefit from revascularization procedures.

Loss of follow-up after carotid revascularization is associated with worse long-term stroke and death

ObjectivesSociety for Vascular Surgery practice guidelines recommend surveillance with duplex ultrasound scanning at baseline (within 3 months from discharge), every 6 months for 2 years, and annually afterward following carotid endarterectomy or carotid artery stenting. There is a growing concern regarding the significance of postoperative follow-up after several vascular procedures. We sought to determine whether 1-year loss to follow-up (LTF) after carotid revascularization was associated with worse outcomes in the Vascular Quality Initiative (VQI) linked to Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database. MethodsAll patients who underwent carotid revascularization in the VQI VISION database between 2003 and 2016 were included. LTF was defined as failure to complete 1-year follow-up in the VQI long-term follow-up dataset. Data about stroke and mortality were captured in the VISION dataset using a list of Current Procedural Terminology, International Classification of Diseases (Ninth Revision), and International Classification of Diseases (Tenth Revision) codes linked to index procedures in VQI. Kaplan-Meier life-table methods and Cox proportional hazard modeling were used to compare 5- and 10-year outcomes between patients with no LTF and those who were LTF. ResultsA total of 58,840 patients were available for analysis. The 1-year LTF rate was 43.8%. Patients who were LTF were older and more frequently symptomatic, with chronic obstructive pulmonary diseases, chronic kidney diseases, and congestive heart failure. Also, patients who underwent carotid artery stenting were more likely to be LTF compared with carotid endarterectomy patients (54.5% vs 42.3%; P < .001). The incidence of postoperative (30 days) stroke was higher in the LTF group (2.9% vs 1.7%; P < .001). Cox regression analysis revealed that LTF was associated with an increased risk of long-term stroke at 5 years (hazard ratio [HR]: 1.4, 95% confidence interval [CI]: 1.2-1.6; P < .001) and 10 years (HR: 1.3, 95% CI: 1.2-1.5; P < .001). It was also associated with significantly higher mortality at 5 years (HR: 2.5, 95% CI: 2.3-2.8; P < .001) and 10 years (HR: 2.2, 95% CI: 1.9-2.5; P < .001). Stroke or death was significantly worse in the LTF group at 5 years (HR: 2.3, 95% CI: 2.1-2.5; P < .001) and up to 10 years (HR: 2.02, 95% CI: 1.8-2.3; P < .001). ConclusionsOne-year follow-up after carotid revascularization procedures was found to be associated with better stroke- and mortality-free survival. Surgeons should emphasize the importance of follow-up to all patients who undergo carotid revascularization, especially those with multiple comorbidities and postoperative neurological complications.

Use of Transcarotid Artery Revascularization, Transfemoral Carotid Artery Stenting, and Carotid Endarterectomy in the US From 2015 to 2019

A transcarotid artery revascularization (TCAR) device was approved by the US Food and Drug Administration in 2015 for carotid revascularization in patients at high risk for stroke, cranial nerve injury, or major cardiac event. It is unclear how the introduction of TCAR has changed the use of carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS). To quantify the temporal changes in the operative approach to carotid revascularization (CEA vs TFCAS vs TCAR), and to identify patient and disease characteristics commonly associated with each approach. This retrospective cohort study obtained data from the Vascular Quality Initiative database from January 1, 2015, to December 31, 2019. Patients with carotid artery stenosis who underwent CEA, TFCAS, or TCAR were included. Data were analyzed from January to April 2022. Month and year of surgery as well as patient risk status. Number and proportion of carotid revascularization procedures by operative approach. A total of 108 676 patients (mean [SD] age 56.6 [12.5] years; 66 684 men [61.4%]) were included in the analysis. The most common operative approach overall was CEA (n = 81 508 [75.0%]), followed by TFCAS (n = 15 578 [14.3%]) and TCAR (n = 11 590 [10.7%]). The number of procedures increased over the study period (16 754 in 2015 vs 27 269 in 2019; P < .001). In 2015, CEA was used in 84.9% of all cases, followed by TFCAS (14.4%) and TCAR (0.8%). In 2019, CEA was used in 64.8% of cases, followed by TCAR (21.9%) and TFCAS (13.3%). The proportional use of CEA decreased by 5.0% (95% CI, -7.4% to -2.6%) per year, and TCAR use increased by 5.3% (95% CI, 2.3%-8.3%) per year. Among patients at high risk, the change was greater: CEA use decreased by 7.8% (95% CI, -11.9% to -3.8%) per year, TFCAS decreased by 4.8% (95% CI, -9.5% to -0.14%) per year, and TCAR increased by 12.6% (95% CI, 7.1%-18.1%) per year. Multinomial logistic regression showed that patient risk status was the most important characteristic associated with TCAR compared with CEA (relative risk ratio, 36.10; 95% CI, 29.24-44.66; P < .001) and TFCAS (relative risk ratio, 14.10; 95% CI, 11.86-16.66; P < .001). Linear regression revealed no association between year of surgery and in-hospital myocardial infarction, stroke, or mortality. Results of this study indicate that TCAR has become the dominant carotid revascularization approach, surpassing TFCAS and CEA in patients at high risk for stroke, cranial nerve injury, or cardiovascular events. Patient high-risk status was the main characteristic associated with a stenting approach, highlighting the perceived importance of carotid stenting therapies in this patient population.