Carotid Stenting Research Articles

Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease

ObjectiveStroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate. MethodsWe aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS). ResultsTwo randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively). ConclusionsCEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.

Associations between preprocedural carotid artery perivascular fat density and early in-stent restenosis after carotid artery stenting

ObjectivesThis study investigated the association between perivascular fat density (PFD) via preoperative computed tomographic angiography (CTA) and early in-stent restenosis (ISR) after carotid artery stenting (CAS). MethodsWe retrospectively evaluated 248 consecutive patients who had undergone initial CAS and received a preoperative cervical CTA examination between January 2019 and October 2020. The patients were categorized into two according to whether they sustained ISR during the 2 years postoperative follow-up period. Correlations between PFD and ISR were assessed, and multivariate regression for evaluating predictors of ISR was conducted. Receiver operating characteristic (ROC) curves were used to determine the cutoff value for the PFD. ResultsA total of 181 eligible patients (mean age 61.25 ± 10.35 years, 57 male) were enrolled. The ISR group had a higher proportion of closed-cell stents (48.8% versus 27.5%; p = 0.009) and a greater degree of residual stenosis (28[20,33] % versus 20[14.75,30] %; p < 0.001) than the non-ISR group. The ISR group had a higher mean HU value of PFD than the non-ISR group on the operated side (−42.26 ± 6.81 versus −59.66 ± 10.75; p < 0.001). The degree of residual stenosis (OR 1.146, 95%CI 1.071–1.226, p < 0.001) and PFD on the operated side (OR1.353, 95%CI 1.215–1.506, p < 0.001) were significantly associated with the ISR. ConclusionsThe occurrence of the early ISR after CAS is associated with a higher PFD on the operated side. The results indicate that PFD is a promising marker to predict the ISR after CAS.

Acute carotid stenting plus aspirin during thrombectomy of tandem occlusions: A matched case-control study.

Acute carotid artery stenting (CAS) for ischemic stroke patients with anterior circulation tandem occlusion requires periprocedural antiplatelet therapy to prevent stent thrombosis. However, due to the lack of randomized trials and inconsistent published results, there is no reliable information regarding the safety of additional antiplatelet treatment. Therefore, we compared the safety and functional outcomes of patients treated with acute CAS plus Aspirin during tandem occlusions thrombectomy with isolated intracranial occlusions patients treated with thrombectomy alone. Two prospectively acquired mechanical databases from August 2017 to December 2021 were reviewed. Patients were included if they had carotid atherosclerotic tandem occlusions treated with acute CAS and Aspirin (intravenous bolus 250 mg) during thrombectomy. Any antiplatelet agent was added after thrombectomy and before the 24-h control imaging. This group was compared with a matched group of isolated intracranial occlusions treated with thrombectomy alone. A total of 1557 patients were included and 70 (4.5%) had an atherosclerotic tandem occlusion treated with acute CAS plus Aspirin during thrombectomy. In exact coarse matched weight adjusted analysis, the rate of symptomatic intracerebral hemorrhage was similar in both groups (OR, 3.06; 95% CI, 0.66-14.04; P = 0.150), parenchymal hematoma type 2 (OR, 1.15; 95% CI, 0.24-5.39; P = 0.856), any intracerebral hemorrhage (OR, 1.84; 95% CI, 0.75-4.53; P = 0.182), and 90-day mortality (OR, 0.79; 95% CI, 0.24-2.60; P = 0.708). Rates of early neurological improvement and 90-day modified Rankin Scale score 0-2 were comparable. Acute CAS plus Aspirin during thrombectomy for tandem occlusion stroke appears safe. Randomized trials are warranted to confirm these findings.

A Scoping Review of Simulation-Based Training Paradigms for Carotid Artery Endarterectomy and Carotid Artery Stenting

Surgical simulation has come to the forefront to enhance the training of residents. The aim of our scoping review is to analyze the available simulation-based carotid revascularization techniques, including carotid endarterectomy (CEA) and carotid artery stenting (CAS) and suggest critical steps for evaluating competency in a standardized fashion. A scoping review of all reports on simulation-based carotid revascularization techniques including CEA and CAS was performed in PubMed/MEDLINE, Scopus, Embase, Cochrane, Science Citation Index Expanded, Emerging Sources Citation Index, and Epistemonikos databases. Data were collected according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The English language literature was searched from January 1, 2000 to January 9, 2022. The outcomes evaluated included measures of assessment of operator performance. Five CEA and 11 CAS manuscripts were included in this review. The methods of assessments employed by these studies to judge performance were comparable. The 5 CEA studies sought to validate and demonstrate improved performance with training or distinguish surgeons by their experience level, either through assessing operative performance or end-product results. The 11 CAS studies used 1 of 2 types of commercial simulators and focused on determining the efficacy of simulators as teaching tools. By examining the steps of the procedure associated with preventable perioperative complications, it provides a reasonable framework for determining which elements of the procedure should be emphasized most. Furthermore, using potential errors as a basis for assessment of competency could reliably distinguish operators based on level of experience. Competency-based simulation training is becoming more relevant as our surgical training paradigm shifts with the increased scrutiny within training programs of work-hour regulations and the need to develop a curriculum to assess our trainees' ability to perform specific operations competently during their stipulated training period. Our review has given us an insight into the current efforts in this space regarding 2 specific procedures that are key for all vascular surgeons to master. Although many competency-based modules are available, there is a lack of standardization in the grading/rating system of what surgeons consider vital steps of each procedure to assess these simulation-based modules. Therefore, the next steps of curriculum development should be based on standardization efforts for the different protocols available.

Risk of Reintervention Is Lower for Carotid Endarterectomy Than Carotid Artery Stenting

Perioperative outcomes for carotid endarterectomy (CEA) and carotid artery stenting (CAS) have been well-studied. Less is known about the durability and reintervention rates of each, particularly in the era of transcarotid artery revascularization (TCAR). We sought to compare real-world rates of ipsilateral reintervention, stroke, and death in patients undergoing CEA and CAS, with an additional analysis of CAS patients comparing reintervention between transfemoral stenting (TFCAS) and TCAR. The Vascular Quality Initiative (VQI) was matched to Medicare claims via the Vascular Implant Surveillance and Implantation Network database, and we identified patients who had primary carotid revascularization from December 2016 to December 2019. The primary outcome was ipsilateral reintervention, while secondary outcomes included stroke and mortality. After 1:1 greedy matching using propensity scores, patients who underwent CEA and CAS were compared within 6 months following the index procedure and from 6 months to 3 years separately using time-dependent Cox regression models. A separate propensity matched analysis was then performed to compare TFCAS and TCAR. Kaplan-Meier curves were compared using log-rank tests. We identified 27,944 patients undergoing CEA (n = 21,256) or CAS (n = 6688). After propensity matching, we compared 4705 patients in each group. Risk of reintervention was increased within 6 months for CAS (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.11-3.50; P < .05), but not beyond 6 months (HR, 1.08; 95% CI, 0.62-1.89; P = .79). The incidence of stroke prior to discharge was increased in patients undergoing CAS (5.4% vs 1.0%; P < .0001), and similarly was increased within 6 months (HR, 2.91; 95% CI, 2.42-3.48; P < .0001) but not beyond 6 months. However, mortality for CAS was increased both within 6 months (HR, 1.69; 95% CI, 1.38-2.07; P < .0001) and beyond 6 months (HR, 1.52; 95% CI, 1.27-1.81; P < .0001). When comparing TFCAS and TCAR (n = 2115 per group), there was a significantly increased risk of reintervention for TFCAS beyond 6 months (HR, 2.31; 95% CI, 1.05-5.11; P < .05), but not within 6 months (HR, 1.56; 95% CI, 0.71-3.43; P = .27) (Figure). CEA portends a lower risk of reintervention than CAS, particularly within the first 6 months after intervention. We also confirm prior data suggesting lower rates of ipsilateral stroke and death with CEA compared to CAS. On subgroup analysis of stenting modalities, TCAR had a lower rate of reintervention than TFCAS. CEA appears to be the most durable carotid revascularization strategy, with TCAR being more durable among stenting procedures.

Protamine Sulfate Following Carotid Artery Stenting: Does the Patient’s Gender Matter?

Protamine sulfate can be administrated to decrease the risk of bleeding after the carotid artery stenting (CAS) procedure. Although a few studies reported data regarding the efficacy and safety of protamine, the existing literature assessing its impact under more personalized patient circumstances is limited. Therefore, in this study, we aimed to identify the potential factors where the patients are more likely to benefit from protamine sulfate after CAS procedures. A retrospective review of Vascular Quality Initiative data between 2016 and 2022 to identify all patients who underwent CAS procedures was performed. The patients were divided into two groups based on the surgical approach: transfemoral CAS (TF-CAS) and transcarotid artery revascularization (TCAR). A multivariate model was conducted to identify the perioperative predictors of bleeding complications in each cohort. In addition, a propensity score matching was performed to compare the rates of thrombotic events between protamine vs no protamine groups in both cohorts. A total of 61,686 patients were identified; 36.6% were female. Approximately 53% of the patients underwent TCAR (protamine: 85.6%; no protamine: 14.4%), whereas TF-CAS was performed in 46.8% (protamine: 18.9%; no protamine: 81.1%). Protamine use was associated with a decreased risk of bleeding complications after TCAR (0.26 [0.2-0.3]; P < .001) but not TF-CAS (1.06 [0.8-1.3]; P = .6164). However, the protamine beneficial impact is more apparent among the female patients regardless of the surgical approach (Table). In addition, no significant increase was noted in the thrombotic complications in both TF-CAS (protamine vs no protamine: death, 7.9% vs 11.5%; myocardial infarction, 0.5% vs 0.9%; stroke/transient ischemic attack, 2.8% vs 2.9%; P > .05 for all, except death P < .001) and TCAR (protamine vs no protamine: death, 7.7% vs 7.3%; myocardial infarction, 0.4% vs 0.3%; stroke/transient ischemic attack, 2.4% vs 2.9%; P > .05 for all) groups. Protamine sulfate appears to be effective in reducing the bleeding complications in patients who undergo TCAR but not TF-CAS, without an increase in the thrombotic complications. However, this beneficial impact is more significant among female patients regardless of the CAS approach.TablePerioperative predictors of bleeding complications after TCAR and TF-CASaCovariatebNo protamineProtamineAdjusted odds ratio (95% CI)P valueAdjusted odds ratio (95% CI)P value(A) TCAR Sex (female)1.45 (1.2-1.9).00501.08 (0.9-1.3).4639 Race (Asian) (Ref: White)4.29 (1.4-13.1).01041.31 (0.6-3.0).5139 Symptomatic CHF1.67 (1.1-2.6).02451.21 (0.8-1.7).3206(B) TF-CAS Sex (female)1.76 (1.4 – 2.2)<.0011.14 (0.8 – 1.7).5277ACEI, Angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CHF, congestive heart failure; CI, confidence interval; COPD, chronic obstructive pulmonary disease; TCAR, transcarotid artery revascularization; TF-CAS, transfemoral carotid artery stenting.aOnly the perioperative predictors that were statistically significant on the univariate and multivariate analysis are shown in this table.bOther covariates: age ≥65, Hispanic ethnicity, comorbidities (hypertension, diabetes, dialysis status, smoking, and COPD), perioperative medications (aspirin, antiplatelet, statin, β-blockers, ACEIs/ARBs), and type of anesthesia. Open table in a new tab

Impact of Head and Neck Radiation on Long-term Outcomes After Carotid Revascularization

Radiation-induced carotid artery stenosis is a well-described phenomenon seen after treatment for head and neck cancer. Previously published literature suggests that compared to atherosclerotic disease, radiation-induced carotid artery stenosis may result in poorer long-term outcomes and early restenosis. The study aims to evaluate the effect of radiation on long-term outcomes after various carotid revascularization techniques using a multicenter registry database. Patients in the Society for Vascular Surgery Vascular Quality Initiative registry for carotid artery intervention (carotid endarterectomy, CEA; transfemoral carotid artery stenting, CAS; transcarotid artery revascularization, TCAR), who are 65 years or older were included in the study. Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network Medicare-linked database was used to obtain long-term procedure-specific outcomes. Primary end points were 3-year death, stroke, and reintervention. We performed propensity matching between patients with prior radiation and those without. Kaplan-Meier analysis and a multivariate logistic regression model were used to analyze the outcome variables. There were 1244 patients with prior radiation and 54,925 patients without prior radiation. Prior radiation group was more likely to be male (71.9% vs 60.3%; P ≤ .01), more likely to receive a stent (47.5% vs 13.5%; P < .01), and more likely to be on P2Y12 inhibitor (55.2% vs 38.3%; P < .01). Propensity matching was performed on 1223 patients (CEA, n = 655; TCAR, n = 292; CAS, n = 287). There were no significant differences in 30-day outcomes for death, stroke, or major adverse cardiovascular events for all three procedures (Table). The prior radiation group had higher rates of cranial injury (3.7% vs 1.8%; P = .04) and 90-day readmission (23.5% vs 18.3%; P = .01) after CEA. For long-term outcomes, prior radiation significantly increased mortality risk for CEA and CAS (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.38-2.27 and HR, 1.56; 95% CI, 1.02-2.36, respectively). The 3-year risk of stroke for CEA in radiated patients was also significantly higher (HR, 1.47; 95% CI, 1.03-2.09) compared to nonradiated patients. Prior radiation did not significantly affect death and stroke in patients undergoing TCAR. Prior radiation also did not impact the rates of short and long-term reintervention after CEA, CAS, or TCAR. Prior head and neck radiation significantly increases the risk for mortality and stroke for CEA and the risk for mortality after CAS. Long-term outcomes for TCAR are not significantly affected by prior radiation. TCAR may be the preferred treatment modality for patients with radiation-induced carotid stenosis.TableHR95% CIP valueCEA Death1.771.38-2.27<.01 Stroke1.471.03-2.09.03 Reintervention1.260.87-1.82.21CAS Death1.561.02-2.36.04 Stroke0.910.56-1.46.68 Reintervention1.710.86-3.38.13TCAR Death1.100.60-2.03.76 Stroke1.470.66-3.31.35 Reintervention0.980.54-1.79.96All Death1.371.12-1.68<.01 Stroke0.980.75-1.27.85 Reintervention1.240.94-1.64.13CAS, Carotid artery stenting; CEA, carotid endarterectomy; CI, confidence interval; HR, hazard ratio; TCAR, transcarotid artery revascularization. Open table in a new tab

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

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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Transcarotid Revascularization Outcomes Are Not Affected by the Choice of Antiplatelet with Aspirin

Over one-third of transcarotid revascularization (TCAR) patients demonstrate mild to severe resistance to clopidogrel resulting in an increase in hematologic testing and potential healthcare costs. This investigation was completed to determine if the choice of the second antiplatelet in addition to aspirin affected perioperative outcomes. Consecutive carotid stenting procedures identified from the Vascular Quality Initiative (VQI) from January 2016 to September 2016 were captured. We excluded patients with nonatherosclerotic disease, intracranial disease, and tandem lesions. Two cohorts of patients maintained on dual antiplatelet therapy were compared consisting of aspirin + clopidogrel (AC) and aspirin + prasugrel/ticagrelor (APT). A 1:1 propensity score match including procedure characteristics, age, gender, race, symptomatic status, diabetes, coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, chronic obstructive pulmonary disease, dialysis, smoking status, prior ipsilateral or contralateral coronary artery stenting/carotid endarterectomy, contralateral occlusion, preoperative anticoagulation, urgency, protamine use, and physician case volume was completed to compare perioperative results. Within the specified study period, we captured 38,813 carotid stenting patients on AC and 2346 patients maintained on APT (Table I). Of the AC patients, 25,293 received TCAR while the remaining 13,520 underwent transfemoral stenting. Similarly, 1308 APT patients underwent TCAR and 1038 received transfemoral stenting. Before propensity matching, the crude results noted that APT patients were more likely to experience in-hospital mortality (0.5% vs 1.1%; P < .01), but there was no difference in ipsilateral stroke (1.2% vs 1.1%; P = .62), any stroke (1.5% vs 1.4%; P = .84), or myocardial infarction (MI) (0.5% vs 0.7%; P = .31). After adjustment with our propensity match (Table II), 2047 unique subject pairs were generated. There was no statistical difference with respect to in-hospital mortality (0.6% vs 0.9%; P = .30), ipsilateral stroke (1.4% vs 1.0%; P = .41), any stroke (1.5% vs 1.3%; P = .85), MI (0.8% vs 0.8%; P = .84), or stent thrombosis (0.1% vs 0.3%; P = .18). Additionally, there was no difference in the combined outcomes of stroke/death (1.9% vs 2.0%; P = .63) or stroke/death/MI (2.6% vs 2.7%; P = .74). As testing for antiplatelet resistance has become more prominent in the last several years, we evaluated and noted no variability between study groups before or after a procedure date in 2019. No difference in perioperative stroke, death, and/or stent occlusion are noted after TCAR in patients maintained on AC compared to APT. Therefore, routine testing for clopidogrel resistance is an unnecessary healthcare cost which can be eliminated.Table IACAPTP valuen = 38,813 (94.3)2346 (5.7)Prasugrel346 (14.75)Ticagrelor2000 (85.2)Procedure<.001 Transcarotid artery revascularization25,293 (65.2)1308 (55.7) Transfemoral carotid artery stenting13,520 (34.8)1038 (44.3)Surgery year<.001 2016706 (1.8)37 (1.6) 20173044 (7.8)139 (5.9) 20184666 (12.0)199 (9.5) 20197066 (18.2)379 (16.2) 20207560 (19.5)457 (19.5) 20219836 (25.3)716 (30.5) September 20225935 (15.3)419 (17.9)AC, Aspirin + clopidogrel; APT, aspirin + prasugrel/ticagrelor. Open table in a new tab Table IIBefore PSM (crude outcomes)1:1 PSM (adjusted outcomes)aACAPTP valueACAPTOR (95% CI)bP valuen = 38,813 (94.3)2346 (5.7)n = 2047n = 2047In-hospital outcomes Death204 (0.5)25 (1.1)<0.0113 (0.6)19 (0.9)1.49 (0.70-3.18).30 Ipsilateral stroke457 (1.2)25 (1.1)0.6229 (1.4)21 (1.0)0.77 (0.42-1.43).41 Stroke549 (1.45)32 (1.40)0.8430 (1.5)27 (1.3)0.94 (0.53-1.67).85 MI204 (0.5)16 (0.7)0.3117 (0.8)16 (0.8)0.93 (0.45-1.91).84 Stroke/death680 (1.8)50 (2.1)0.1838 (1.9)41 (2.0)1.13 (0.69-1.83).63 Stroke/death/MI844 (2.2)65 (2.8)0.0653 (2.6)56 (2.7)1.08 (0.70-1.65).74 Bleeding requiring intervention229 (0.6)15 (0.6)0.7611 (0.5)14 (0.7)1.28 (0.56-2.84).54 Immediate restenosis/occlusion63 (0.2)7 (0.3)0.122 (0.1)6 (0.3)3.0 (0.60-14.8).18AC, Aspirin + clopidogrel; APT, aspirin + prasugrel/ticagrelor; CI, confidence interval; MI, myocardial infarction; OR, odds ratio; PSM, propensity score matching.Values are number (%) unless otherwise stated.aNo interaction between antiplatelet regimen and type of procedure in predicting outcome and between antiplatelet regimen and surgeries performed before or after 2019 (P > .10). Open table in a new tab

Perioperative Outcomes After Carotid Revascularization in Asian Patients Varies With Asian Procedure Density

The nature of postoperative outcomes following carotid revascularization is understudied in Asian patients. We aimed to determine if there are disparities in disease severity and postoperative outcomes in Asian patients following carotid revascularization and whether this varies with procedure frequency in Asian patients. We analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy and Carotid Artery Stenting datasets from 2003 to 2021. We divided regions into tertiles based on Asian procedure density. Propensity scores were used to match White and Asian patients based on age, sex, comorbidities, contralateral carotid occlusion, and procedure type. Logistic and Cox regressions were performed within the matched cohort. The primary outcome variable was in-hospital ipsilateral stroke/death/myocardial infarction and we also examined differences in disease severity, center and surgeon volume, and late outcomes. A total of 159,608 White and 1766 Asian patients underwent carotid revascularization and we identified 2704 patients in the matched cohort. On adjusted analysis, there was no difference in symptomatic disease rate between groups (35%). However, Asian patients more commonly presented with >80% ipsilateral stenosis (63% vs 52%; P < .001) and a moderate/severe preoperative Rankin score (7.6% vs 5.1%; P = .007), which did not vary with Asian procedure density. The rate of in-hospital stroke/death/myocardial infarction was higher in Asian patients (2.6% vs 1.3%; P = .012), and this disparity was more pronounced in the lowest tertile of Asian procedure density (4.3% vs 0.5%; P < .001). Logistic regression within the propensity-matched cohort demonstrated Asian race was associated with a decreased odds of care by highest volume centers and surgeons, which was largely consistent across tertiles of Asian procedure density (Table I). Asian race was associated with twofold greater odds of in-hospital stroke/death/myocardial infarction, which was driven by the lowest tertile regions of Asian procedure density. After clustering at surgeon and center level, the effect of Asian race was mitigated. Cox regression within the matched cohort demonstrated that Asian race was protective against late mortality, with no differences in 1-year stroke or reintervention-free survival (Table II). Asian patients are more likely to present with a greater degree of carotid stenosis, preoperative risk, and experience worse perioperative outcomes. The increased odds of perioperative stroke/death/myocardial infarction is driven by regions with low Asian procedure density and is also mediated by the volume of centers and surgeons with which Asian patients tend to undergo care. These results highlight the need to understand the social and cultural effects on outcomes disparities in Asian patients.Table ILogistical regression of outcomes in propensity-matched cohortAssociation With Asian RaceOR (95% CI; P)ORa (95% CI; P)In-hospital stroke/death/myocardial infarction2.1 (1.2-3.7; P = .014)1.4 (0.7-3.0; P = .354)Operation at highest volume centers0.2 (0.2-0.3; P < .001)--Operation with highest volume surgeons0.3 (0.3-0.4; P < .001)--CI, Confidence interval; OR, odds ratio.aLogistical regression with clustering at surgeon and center level. Open table in a new tab Table IICox regression of late outcomes in propensity-matched cohortAsian RaceHR (95% CI, P)Long-term mortality0.6 (0.4-0.9; P = .011)1-year stroke-free survival1.1 (0.3-3.9; P = .878)1-year reintervention-free survival5.0 (0.8-33.0; P = .091)HR, Hazard ratio; OR, odds ratio. Open table in a new tab

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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Optimal Method of Carotid Revascularization in Patients With Recent Myocardial Infarction

Recent myocardial infarction (MI) represents a real challenge in patients requiring any vascular procedure. There is currently a lack of data on the effect of preoperative MI on the outcomes of carotid revascularization methodology (carotid enterectomy [CEA], transfemoral carotid artery stenting [TFCAS], or transcarotid artery revascularization [TCAR]). This study looks to identify the ideal revascularization method for patients with recent MI. Data were collected from Vascular Quality Initiative (VQI) (2016-2022) for patients with carotid stenosis in the United States and Canada with recent MI (<6 months) undergoing CEA, TFCAS, or TCAR. In-hospital outcomes after TFCAS vs CEA and TCAR vs CEA were compared. We used logistic regression models to compare the outcomes of these three procedures in patients with recent MI adjusting for potential confounders. Primary outcomes included in-hospital rates of stroke, death, and MI. Secondary outcomes included stroke/death, stroke/death/MI, postoperative hypertension, postoperative hypotension, and prolonged length of stay (>2 days). The final cohort included 1217 (54.2%) CEA, 445 (19.8%) TFCAS, and 584 (26.0%) TCAR cases. Patients undergoing CEA were more likely to have prior coronary artery bypass graft/percutaneous coronary intervention and to use anticoagulant. Patients undergoing TFCAS were more likely to be symptomatic, have prior congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease, and undergo urgent operations. Patients undergoing TCAR were more likely to have higher rates of aspirin class IV-V, protamine, and P2Y12 inhibitor use. In the univariate analysis, CEA was associated with a lower rate of ipsilateral stroke (P = .079) and death (P = .002) (see Table I for secondary outcomes). After adjusting for confounders, TFCAS was associated with increased risk of stroke/death (adjusted odds ratio [aOR]: 2.69; 95% CI: 1.36-5.35; P = .005) and stroke/death/MI (aOR: 1.67; 95% CI: 1.07-2.60; P = .025) compared with CEA. However, TCAR had similar outcomes to CEA (Table II). Both TFCAS and TCAR were associated with increased risk of postoperative hypotension (aOR: 1.71; 95% CI: 1.24-2.36; P = .001 and aOR: 1.82; 95% CI: 1.37-2.41; P ≤ .001, respectively) compared with CEA. However, TCAR was associated with a decreased risk of postoperative hypertension (aOR: 0.55; 95% CI: 0.39-0.75; P ≤ .001) compared with CEA (Table II). Although recent MI has been established as a high-risk criterion for CEA and an approved indication for TFCAS, this study showed that CEA is safer in this population with lower risk of stroke/death and stroke/death/MI compared with TFCAS. TCAR had similar stroke/death/MI outcomes to CEA in patients with recent MI. Further prospective studies are needed to confirm our findings.Table IPostoperative outcomes of carotid enterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) in patients with recent myocardial infarction (MI)In-hospitalUnivariableCEATFCASTCARNo. (%)No. (%)No. (%)P valueStroke27 (2.22)15 (3.40)19 (3.26).277Ipsilateral Stroke19 (1.56)14 (3.17)16 (2.74).079Death14 (1.15)17 (3.82)13 (2.23).002MI28 (2.30)8 (1.80)8 (1.37).398Stroke/death40 (3.29)29 (6.56)28 (4.79).012Stroke/death/MI60 (4.93)36 (8.14)34 (5.82).046Postoperative hypertension278 (22.84)50 (11.26)80 (13.72)<.001Postoperative hypotension187 (15.37)112 (25.23)149 (25.56)<.001Prolonged length of stay565 (46.43)233 (52.36)268 (45.89).068 Open table in a new tab Table IIPostoperative outcomes of transfemoral carotid artery stenting (TFCAS) vs carotid enterectomy (CEA) and transcarotid artery revascularization (TCAR) vs CEA in patients with preoperative myocardial infarction (MI) after adjusting for confounding factors (reference = CEA)In-hospitalMultivariableaTFCAS vs CEATCAR vs CEAOR (95% CI)P valueOR (95% CI)P valueStroke1.30 (0.69-2.47).4131.42 (0.77-2.62).260Ipsilateral stroke1.49 (0.69-3.23).3081.90 (0.87-4.11).105Death2.42 (1.00-5.89).0512.21 (0.89-5.46).086MI0.84 (0.37-1.88).6640.57 (0.24-1.34).197Stroke/death2.69 (1.36-5.35).0051.45 (0.84-2.51).185Stroke/death/MI1.67 (1.07-2.60).0251.10 (0.68-1.78).701Postoperative hypertension0.66 (0.41-1.04).0730.55 (0.39-0.75)<.001Postoperative hypotension1.71 (1.24-2.36).0011.82 (1.37-2.41)<.001Prolonged length of stay (>2 days)1.12 (0.81-1.55).4810.96 (0.72-1.27).761ASA, Aspirin; CABG, coronary artery bypass graft; CHF, congestive heart failure; CI, confidence interval; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention.aMultivariate analysis adjusted for the following confounders: age, gender, race, ethnicity, obesity, symptomatic status, diabetes, hypertension, CHF, COPD, CKD, ASA class, prior occlusions, CABG/PCI, procedure urgency, smoking, and use of preoperative medications. Open table in a new tab

Assessing for Regional Variation in Carotid Artery Stenting Outcomes—The Influence of Age and Cerebral Protection Modality

Assessing for Regional Variation in Carotid Artery Stenting Outcomes—The Influence of Age and Cerebral Protection Modality

Medicare Patients with Symptomatic Carotid Disease Requiring Carotid Revascularization Are Likely to Have Delayed Access: An Analysis of a Multicenter Surgical Data

The Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease recommends carotid revascularization as soon as the patient is neurologically stable after 48 hours and before 14 days of symptom onset in patients with recent stroke. In the United States, insurance status has been demonstrated to play a role in wait times for surgical care. There are no large-scale studies that assess the effect of patient primary insurance status on time to surgery in patients with symptomatic carotid disease. We utilized the Vascular Quality Initiative (VQI) database to evaluate our hypothesis that insurance status is associated with waiting times before surgery in patients with symptomatic carotid disease. All patients who underwent carotid revascularization in the VQI dataset from 2010 to 2022 were included. Patients with incomplete or missing outcomes data, Modified Rankin score of >2 and asymptomatic were excluded. Primary outcome was time between onset of symptomatic carotid disease and intervention. Categorical variables were compared using χ2 test and one-way analysis of variance for continuous variables. Multivariable logistic regression was used to assess the association between insurance status and waiting time to surgery while adjusting for potential confounders. The study consisted of 11,973 patients who had carotid revascularization within 14 days of symptoms (early cohort) and 21,253 patients in the late cohort (after 14 days). Patients in the late cohort were older (70.1 ± 9.8 vs 69.8 ± 10.5; P = .02), less likely to undergo carotid endarterectomy (85.9% vs 88.4%; P < .01), and more likely to have an elective procedure (90.3% vs 44.3%; P < .01). Fig 1 shows the distribution of insurance coverage among the study cohort. After adjusting for potential confounders, compared to Medicare, recipients of other insurer types had lower odds of experiencing delayed surgery: Medicare Advantage (adjusted odds ratio [aOR], 0.89; 95% confidence interval [CI], 0.80-0.99; P = .03), commercial (aOR, 0.84; 95% CI, 0.78-0.90; P < .001), military/Department of Veterans Affairs (aOR, 0.67; 95% CI, 0.54-0.84; P < .001), and self-pay (aOR, 0.54; 95% CI, 0.45-0.65; P < .001). Medicaid patients had similar delay (aOR, 0.90; 95% CI, 0.78-1.03; P = .14) and non-US insurance had longer delay to surgery (aOR, 1.48; 95% CI, 1.13-1.95; P = .005), in comparison to Medicare patients (Fig 2). Symptomatic carotid patients on Medicare and Medicaid are more likely to receive delayed revascularization procedures compared to patient with commercial insurance. Future studies are needed to investigate and potentially mitigate the underlying causes for the delay and the overall health implications of such a delay on the long-term outcomes of these patients.Fig 2Adjusted odds of receiving late carotid revascularization in symptomatic patients requiring surgery: comparing other major insurance providers with Medicare. *Model adjusted for urgency of procedure, prior coronary artery disease, prior carotid endarterectomy/coronary artery stenting, preoperative beta-blocker use, prior congestive heart failure, type of procedure (carotid endarterectomy, transcarotid artery revascularization, transfemoral carotid artery stenting), age, race, body mass index, preoperative creatinine levels, preoperative hemoglobin concentration, preoperative dysrhythmia, previous major amputation, preoperative functional status, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, and degree of stenosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Learning Curve for Transcarotid Artery Revascularization Is Not Affected by Prior Transfemoral Carotid Artery Stenting Experience

The Learning Curve for Transcarotid Artery Revascularization Is Not Affected by Prior Transfemoral Carotid Artery Stenting Experience

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

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

Complications of Carotid Interventions for Symptomatic Lesions After Systemic Thrombolysis

Series detailing complications after carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS) for patients presenting with neurologic symptoms that are treated with systemic thrombolysis (ST) are sparse. We sought to determine if treatment with ST was associated with a higher rate of postcarotid intervention complications. A multispecialty, institutional, prospectively maintained database was queried for symptomatic patients treated with CEA, tfCAS, or transcarotid artery revascularization (TCAR) from 2007 to 2019. Rate of bleeding complications (access/wound complications, hematuria. Intracranial hemorrhage, etc) and return to the operating room was compared between patients who were and were not treated with ST. The rates of stroke and death were also compared. Potential confounding variables were controlled for using inverse probability weighting. There were 1153 patients included (949 [82.3%] CEA, 190 [16.5%] tfCAS, and 14 [1.2%] TCAR). All treated lesions were symptomatic (550 [47.7%] stroke, 603 [52.3%] transient ischemic attack). Fifty-six patients (4.9%) were treated with ST. Fifteen of 56 patients also underwent catheter-based intervention for stroke. ST was administered 0 to 1 days preoperatively in 19 (33.9%) patients, 2 to 10 days, preoperatively, in 34 (64.2%) patients, and >10 days, preoperatively, in 3 (5.4%) patients. ST patients were more likely to present with stroke (92.8% vs 45.4%; P < .001) and have a higher mean preoperative Rankin score (2.7 ± 0.2 vs 1.1 ± 0.0; P < .001). Unadjusted rate of bleeding/return to operating room was 1.8% for ST group and 3.0% for non-ST group (P = .60). Unadjusted rate of stroke was 3.6% for ST group and 3.3% for non-ST group (P = .91), while perioperative mortality was 5.4% for ST group and 1.2% for non-ST group (P = .009). After adjusting for patient factors, preoperative antiplatelet/anticoagulation, and operative factors, ST was not associated with an increased odds of perioperative bleeding/return to operating room (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.01-0.79; P = .03), stroke (OR, 1.01; 95% CI, 0.20-5.2; P = .98), or death (OR, 1.01; 95% CI, 0.28-3.6; P = .98). ST does not convey a higher risk of complications after CEA, tfCAS, or TCAR. After controlling for other factors, patients that received ST had similar rates of local complications, stroke, and death when compared to non-ST patients. Early carotid intervention is safe, and delays should be avoided in symptomatic patients given the high risk of recurrent stroke.

Regional variation in patient selection, practice patterns, and outcomes based on techniques for carotid artery revascularization in the Vascular Quality Initiative

ObjectiveSignificant regional variation is known with multiple surgical procedures. This study describes regional variation in carotid revascularization within the Vascular Quality Initiative (VQI). MethodsData from the VQI carotid endarterectomy (CEA) and carotid artery stenting (CAS) databases from 2016 to 2021 were used. Nineteen geographic VQI regions were divided into three tertiles based on the average annual volume of carotid procedures performed per region (low-volume: 956 cases [range, 144-1382]; medium-volume: 1533 cases [range, 1432-1589]; and high-volume: 1845 cases [range, 1642-2059]). Patients’ characteristics, indications for carotid revascularization, practice patterns, and outcomes (perioperative and 1-year stroke/death) of different revascularization techniques were compared between these regional groups. Regression models that adjust for known risk factors and allow for random effects at the center level were used. ResultsCEA was the most common revascularization procedure (>60%) across all regional groups. Significant regional variation was observed in the practice of CEA such as variability in the use of shunting, drain placement, stump pressure and electroencephalogram monitoring, intraoperative protamine, and patch angioplasty. For transfemoral CAS, high-volume regions had a higher proportion of asymptomatic patients with <80% stenosis (30.5% vs 27.8%) in addition to higher use of local/regional anesthesia (80.4% vs 76.2%), protamine (16.1% vs 11.8%), and completion angiography (81.6% vs 77.6%) during transfemoral carotid artery stenting (TF-CAS) compared with low-volume regions. For transcarotid artery revascularization (TCAR), high-volume regions were less likely to intervene on asymptomatic patients with <80% stenosis (32.2% vs 35.8%) than low-volume regions. They also had a higher proportion of urgent/emergent procedures (13.6% vs 10.4%) and were more likely to use general anesthesia (92.0% vs 82.1%), completion angiography (67.3% vs 63.0%), and poststent ballooning (48.4% vs 36.8%). For each carotid revascularization technique, no significant differences were noted in perioperative and 1-year outcomes between low-, medium-, and high-volume regions. Finally, there were no significant differences in outcomes between TCAR and CEA across the different regional groups. In all regional groups, TCAR was associated with a 40% reduction in perioperative and 1-year stroke/death compared with TF-CAS. ConclusionsDespite significant variation in clinical practices for the management of carotid disease, no regional variation exists in the overall outcomes of carotid interventions. TCAR and CEA continue to show superior outcomes to TF-CAS across all VQI regional groups.

Young patients undergoing carotid stenting procedures have an increased rate of procedural failure at 1-year follow-up

ObjectiveThe outcomes of patients with premature cerebrovascular disease (age ≤55 years) who undergo carotid artery stenting are not well-defined. Our study objective was to analyze the outcomes of younger patients undergoing carotid stenting. MethodsThe Society for Vascular Surgery Vascular Quality Initiative was queried for transfemoral carotid artery stenting (TF-CAS) and transcarotid artery revascularization (TCAR) procedures between 2016 and 2020. Patients were stratified based on age ≤55 or >55 years. Primary endpoints were periprocedural stroke, death, myocardial infarction (MI), and composite outcomes. Secondary endpoints included procedural failure (defined as ipsilateral restenosis ≥80% or occlusion) and reintervention rates. ResultsOf the 35,802 patients who underwent either TF-CAS or TCAR, 2912 (6.1%) were ≤55 years. Younger patients were less likely than older patients to have coronary disease (30.5% vs 50.2%; P < .001), diabetes (31.5% vs 37.9%; P < .001), and hypertension (71.8% vs 89.8%; P < .001), but were more likely to be female (45% vs 35.4%; P < .001) and active smokers (50.9% vs 24.0%; P < .001) Younger patients were also more likely to have had a prior transient ischemic attack or stroke than older patients (70.7% vs 56.9%; P < .001). TF-CAS was more frequently performed in younger patients (79.7% vs 55.4%; P < .001). In the periprocedural period, younger patients were less likely to have a MI than older patients (0.3% vs 0.7%; P < .001), but there was no significant difference in the rates of periprocedural stroke (1.5% vs 2.0%; P = .173) and composite outcomes of stroke/death (2.6% vs 2.7%; P = .686) and stroke/death/MI (2.9% vs 3.2%; P = .353) between our two cohorts. The mean follow-up was 12 months regardless of age. During follow-up, younger patients were significantly more likely to experience significant (≥80%) restenosis or occlusion (4.7% vs 2.3%; P = .001) and to undergo reintervention (3.3% vs 1.7%; P < .001). However, there was no statistical difference in the frequency of late strokes between younger and older patients (3.8% vs 3.2%; P = .129). ConclusionsPatients with premature cerebrovascular disease undergoing carotid artery stenting are more likely to be African American, female, and active smokers than their older counterparts. Young patients are also more likely to present symptomatically. Although periprocedural outcomes are similar, younger patients have higher rates of procedural failure (significant restenosis or occlusion) and reintervention at 1-year follow-up. However, the clinical implication of late procedural failure is unknown, given that we found no significant difference in the rate of stroke at follow-up. Until further longitudinal studies are completed, clinicians should carefully consider the indications for carotid stenting in patients with premature cerebrovascular disease, and those who do undergo stenting may require close follow-up.

Patient Selection Criteria and Procedural Standardization for Carotid Artery Stenting-A Single Center Experience.

The gold standard for the treatment of carotid artery stenosis is the carotid endarterectomy (CEA). According to current guidelines, carotid artery stenting (CAS) is an alternative. Randomized control trials (RCTs) show significantly higher rates of peri-interventional strokes after CAS compared to CEA. However, these trials were usually characterized by a great heterogeneity in the CAS procedure. In this retrospective analysis from 2012 to 2020, 202 symptomatic and asymptomatic patients were treated with CAS. Patients were carefully pre-selected according to anatomical and clinical criteria. In all cases, the same steps and material were used. All interventions were performed by five experienced vascular surgeons. Primary endpoints of this study were perioperative death and stroke. Asymptomatic carotid stenosis was present in 77% of the patients and symptomatic in 23%. The mean age was 66 years. The average degree of stenosis was 81%. The CAS technical success rate was 100%. Periprocedural complications occurred in 1.5% of cases, including one major stroke (0.5%) and two minor strokes (1%). The results of this study indicate that through a strict patient selection based on anatomical and clinical criteria, CAS can be performed with very low complication rates. Furthermore, standardization of the materials and the procedure itself is crucial.