Contralateral Carotid Artery Occlusion Research Articles

Predictors of prolonged length of stay after elective carotid revascularization

ObjectivePostoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization. MethodsPatients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure. ResultsA total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05). ConclusionsA postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.

Carotid Artery Stenting for Patients With Carotid Stenosis and Contralateral Carotid Artery Occlusion: A 12-Year Experience

Carotid artery stenting (CAS) has emerged as a potential alternative for treating patients with extracranial cerebrovascular diseases. Contralateral carotid artery occlusion (CCO) occurs in approximately 2.3% to 25% of patients with carotid artery stenosis. However, the association of a CCO with long-term outcomes after CAS remains unclear. Here, we aimed to evaluate the perioperative and long-term recovery and safety of patients with CCO after receiving CAS. We retrospectively collected the data of patients with CCO treated with CAS between 2010 and 2021. The primary endpoint was a nonfatal major stroke. The secondary endpoints included cerebral hemorrhage, nonfatal myocardial infarction (MI), restenosis, acute renal insufficiency, stent-related complications, and death. Long-term outcomes were analyzed by Kaplan-Meier survival analysis using the following variables: symptomatic carotid stenosis, age, stent type, collateral flow status, and post-dilation. Seventy-one consecutive patients with CCO who underwent CAS were included in the study. Of these, 61 patients (86%) were followed up for 9-134 months, with an average of 63.3 ± 30.4 months. In the perioperative period, 2 patients (2.8%) experienced stroke, and 1 patient (1.4%) died due to cerebral hemorrhage combined with cerebral hernia. During follow-up, 2 patients (3.3%) developed stroke at 4 and 6 months each after CAS, and 6 patients (9.8%) died (2 patients died due to MI, and 4 patients died due to either severe liver failure, car accident, cervical fracture, or unknown cause. Kaplan-Meier survival analysis showed that symptomatic carotid stenosis, age, stent type, and post-dilation were not associated with long-term stroke (P＜0.05). The inadequate collateral flow group showed a higher stroke rate than the control group (P = 0.009). CAS is a safe and effective therapy for patients with CCO. Inadequate collateral flow is associated with a higher long-term rate of stroke. Our findings revealed that symptomatic carotid stenosis, age, stent type, and post-dilation had no significant effect on outcome events after CAS.

A single-center retrospective study with 1-year follow-up after CEA in patients with severe carotid stenosis with contralateral carotid artery occlusion.

ObjectiveTo analyze the risk factors associated with adverse events after carotid endarterectomy (CEA) in patients with unilateral severe carotid stenosis and contralateral occlusion.MethodsPatients were recruited for CEA between August 2014 and February 2020. CEA was performed under general anesthesia. The carotid clamp time (CCT; long CCT: >20 min) is defined as the period between clamp-on and clamp-off for the stenotic carotid artery. The perioperative factors and postoperative adverse events were recorded. All patients were followed up for 1 year after CEA.ResultsSixty subjects (65.8 ± 7.2 years; 54 males) were included. Patients with adverse events had significantly longer CCT than those without adverse events (60% vs. 40%, P = 0.013). Univariate logistic regression analysis showed that a history of diabetes was significantly associated with adverse events (OR, 0.190; 95% CI, 0.045–0.814; P = 0.025); long CCT was significantly associated with adverse events (OR, 8.500; 95% CI, 1.617–44.682; P = 0.011). After adjusting for confounding factors, including age, sex, BMI, diabetes, PSV, long CCT, non–use of shunt, and history of stroke or TIA, the associations between diabetes and adverse events (OR, 0.113; 95% CI, 0.013–0.959; P = 0.046) were statistically significant; the associations between long CCT and adverse events (OR, 1.301; 95% CI, 1.049–1.613; P = 0.017) were statistically significant.ConclusionsA longer carotid clamp time (>20 min) and a history of diabetes may increase the risk of adverse events in patients with unilateral severe carotid stenosis and contralateral occlusion after CEA. With good preoperative evaluation and intraoperative monitoring, the use of shunts may not be needed intraoperatively in patients with unilateral severe carotid stenosis and contralateral occlusion.

Risk for Additional Infarction in Emergency Carotid Artery Endarterectomy in Thrombectomy Acute Stroke Patients.

Purpose: Thromboembolic occlusion of the middle cerebral artery with tandem occlusion of the internal carotid artery is a life-threatening condition with unfavorable neurological outcome. We perform emergency carotid endarterectomy in the same anesthesia session as thrombectomy in our angiography suite whenever needed despite the absence of electrophysiological neuromonitoring. Methods: We evaluated 47 thrombectomy patients with emergency CEA in our clinic between June 2013 and November 2020. To determine whether there were additional infarctions due to the surgical procedure, we assessed the initial diagnostic CT imaging for previously infarcted areas, cerebral perfusion, and vascular anatomy, including collateralization in the Circle of Willis (CoW). We then analyzed follow-up imaging with respect to new infarctions that could not be explained by the initial stroke. Results: 5 of 47 (11%) patients had a complete CoW. There was contralateral internal carotid artery (ICA) stenosis or occlusion in 18/47 (38%) patients. Surgical procedure was eversion CEA in 34 (72%) and with a patch graft CEA in 13 (28%) cases. Shunts were used during surgery in 17/47 (36%) patients. Two patients suffered from an additional infarction in a new territory, however this was not caused by the surgical procedure but due to embolism during endovascular thrombectomy. In 1 of these 2 patients a hemodynamic border zone infarction was also observed, which could have developed during thrombectomy as well as during surgery, although this could not be attributed with absolute certainty to the surgery. The final infarction size was significantly larger in patients with contralateral ICA stenosis or occlusion (P = .038). Neither CoW anatomy nor the absence of a shunt during surgery could be identified as risk factors for additional infarction. Conclusion: Emergency surgery in the angiography suite without neuromonitoring was not associated with an increased additional stroke rate in our patient cohort.

Risk Factors for and Intraoperative Management of Intolerance to Flow Reversal in TCAR

BackgroundIn patients deemed high risk for carotid endarterectomy (CEA) who are indicated for treatment of carotid artery stenosis (CAS), transcarotid artery revascularization (TCAR) has been demonstrated as a safe and effective alternative to trans-femoral carotid artery stenting (TF-CAS). Compared to CEA, where approx. 12% of patients undergoing awake intervention do not tolerate internal carotid artery (ICA) clamping, only 1–2% of patients were observed to have intolerance to flow reversal during TCAR based on data from the ROADSTER1/2 trials. This study reviewed awake interventions from those trials to assess factors associated with intolerance to flow reversal and review how those cases were managed. MethodsThis is a retrospective review of prospectively collected data from Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial along with the subsequent post-approval (ROADSTER-2) trial. The subset of patients from both trials undergoing awake TCAR was analyzed to compare demographics, procedural details, and anatomic factors between patients who did and did not experience intolerance to reversal of flow to assess for predisposing factors. Patients were deemed intolerant to flow reversal at the discretion of the operator, often related to changes in completion of neurologic tasks, hemodynamic stability, or patient reported symptoms. ResultsA total of 103 patients from ROADSTER and 194 patients from ROADSTER-2 underwent TCAR under local/regional anesthesia. Of these, 8 patients had intolerance to flow reversal, though all cases were successfully completed. While intraoperative hemodynamic data was only available for 5 of the 8 intolerant patients, none experienced hypotension. 4 cases were completed under low flow reversal, 3 cases were successfully weaned from low to high flow over several minutes, and 1 case required general anesthesia. No significant association was found between intolerance to flow reversal and comorbidities including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), congestive heart failure (CHF), prior MI or angina, pre-op CAS-related symptoms, prior stroke, prior CAS or CEA, prior neck radiation, tandem stenosis, high cervical stenosis, or hostile neck. A trend towards significance was seen with chronic obstructive pulmonary disease (COPD) and contralateral carotid artery occlusion (P = 0.086 and 0.139, respectively). ConclusionsDespite intolerance to flow reversal, TCAR cases were successfully completed by adjusting reversal-of-flow rate and do not typically require conversion to GETA. While factors contributing to intolerance of flow reversal during TCAR remain poorly understood, this study identified a trend towards significance with an association of preexisting COPD and contralateral carotid artery occlusion. Given the low number of patients who experienced this issue, a larger sample size is required to better elucidate these trends.

Carotid sinus syndrome in carotid angioplasty with stenting

Introduction. Significant progress has been made in primary stroke prevention, including through the widespread use of carotid angioplasty with stenting (CAS). At the same time, there is a growing number of publications reporting the development of carotid sinus syndrome (CSS) (haemodynamic instability) in the periope- rative period, as well as cerebral and cardiac complications and death, which requires in-depth study to improve the quality of medical care for patients with carotid artery stenosis.&#x0D; The aim of the study was to determine the frequency, risk factors, clinical features and outcomes of CSS in patients with carotid artery stenosis undergoing CAS.&#x0D; Materials and methods. The study included 120 patients with carotid artery disease, who underwent an elective surgical intervention consisting of transluminal balloon angioplasty. All patients underwent comprehensive clinical and laboratory tests and imaging studies.&#x0D; Results. CSS developed in 70% of cases (n = 84) of carotid artery stenosis, and was significantly more common in men than women (71.4% vs. 28.6%, respectively) (p 0.05). The median age of all patients with CSS was 68 (4491) years. Mixed form of CSS was significantly more common than the cardioinhibitory or vasodepressor forms (p 0.05). In more than half of all cases, symptoms developed during balloon dilatation or within an hour afterwards. The duration of CSS was 3040 hours. Contralateral carotid occlusion was detected in 12 (10%) patients, significantly (p 0.05) more often in patients with CSS (13%) compared to patients without CSS (2.8%).&#x0D; Conclusion. Regardless of stenosis severity or symptoms, CAS is accompanied by CSS in 2/3 of cases. The CSS is predominantly a mixed type and can be accompanied by loss of consciousness in rare cases. CSS appears both intraoperatively and in the early postoperative period, and its average duration is 1.5 days. A factor that may be associated with CSS development is contralateral carotid artery occlusion (p 0.05).

Outcomes of Carotid Revascularization in Patients with Contralateral Carotid Artery Occlusion

Outcomes of Carotid Revascularization in Patients with Contralateral Carotid Artery Occlusion

Outcomes of Carotid Revascularization in Patients with Contralateral Carotid Artery Occlusion

Little is known about the best revascularization procedure for patients with contralateral carotid artery occlusion (CCO). We aim to compare the outcomes of transcarotid artery revascularization (TCAR), carotid endarterectomy (CEA), and transfemoral carotid artery stenting (TFCAS) in patients with CCO. Patients in the Vascular Quality Initiative dataset who underwent CEA, TFCAS, or TCAR, and had CCO between September 2016 and April 2020, were included. Multivariable logistic analysis was used to evaluate in-hospital outcomes. The final cohort included 1,144 TCARs, 1,182 TFCAS, and 2,527 CEA procedures performed in patients with CCO. Compared with TFCAS, TCAR was associated with a significant reduction in the odds of in-hospital stroke or death (odds ratio [OR] 0.26; 95% CI: 0.12-0.59; p < 0.01). However, no significant difference in stroke was noted (OR 0.71; 95% CI 0.34-1.51; p= 0.38). These results persisted after stratifying with respect to symptomatic status (p values of interaction= 0.92 and 0.74, respectively). There was no significant difference between TCAR and CEA in odds of in-hospital stroke or death on multivariable adjustment (OR 0.57; 95% CI: 0.29-1.10, p= 0.10). The interaction between procedure type and symptomatic status in predicting in-hospital stroke was statistically significant (p= 0.04). In asymptomatic patients, TCAR was associated with a 50% to 60% reduction in the odds of stroke (p= 0.04). Yet, no significant differences were observed in symptomatic patients. TCAR has lower odds of in-hospital stroke or death compared to TFCAS, independent of symptomatic status. Compared to CEA, TCAR seems to be a better option in asymptomatic patients, with lower odds of in-hospital stroke. Yet, no significant difference is observed in symptomatic patients.

Influence of contralateral carotid artery occlusions on short- and long-term outcomes of carotid artery stenting: a retrospective single-center analysis and review of literature

Influence of contralateral carotid artery occlusions on short- and long-term outcomes of carotid artery stenting: a retrospective single-center analysis and review of literature

Influence of contralateral carotid artery occlusions on short- and long-term outcomes of carotid artery stenting: a retrospective single-center analysis and review of literature.

In the current literature, correlations between a contralateral carotid artery occlusion (CCO) with mortality and major adverse cardiac or cerebrovascular events (MACCE) rates after carotid artery stenting (CAS) are often described with controversial conclusions. Moreover, long-term results of mortality, MACCE and restenosis rate are scarcely reported. This study examined the association between a CCO and the short- and long-term outcomes after CAS. One hundred and forty-six patients with CCO and without (No-CCO) who underwent between 2010 and 2017 to a CAS procedure in a single institution were retrospectively evaluated. The primary aim of the study was to evaluate mortality and MACCE rates in the short-term (defined as the occurrence during hospitalization and within 30-day) and after 3-year follow-up. The secondary aim of the study was to examine the restenosis rates in the short- and long-term period. The overall success of CAS was 99.3% and the 30-day all-cause mortality rate was 0.7% (one death). About MACCE, there were no major strokes in the CCO groups and 1 (1.4%) in the No-CCO group (P=1.00). The rate of 30-day minor strokes was 1.4% (1 patient) in the CCO group and 2.7% (2 patients) in the No-CCO group (P=1.00). In the 3-year follow-up, death occurred in 11 CCO vs. 6 No-CCO patients, respectively (15.1% vs. 8.2%, P=0.30). Regarding MACCE, major stroke occurred in 6 CCO vs. 2 No-CCO patients (8.2% vs. 2.7%, P=0.27), minor stroke in 6 CCO vs. 6 No-CCO (8.2% vs. 8.2%, P=1.0) and myocardial infarction in 6 CCO (8.2%) vs. 3 No-CCO patients (8.2 vs. 4.1%, P=0.49), respectively. Regarding the 30-day restenosis rate, it was observed in one patient (1.4%) in the CCO group while no cases were recorded in the No-CCO group, respectively (P=1.00). In the 3-year follow-up, greater than >50% restenosis was observed in 7 patients (9.6%) in the CCO group and in one patient (1.4%) in the No-CCO group (P=0.06), respectively. Kaplan-Meier survival analysis revealed that CCO patients had a lower 3-year freedom from restenosis rate with respect to the No-CCO group (87.6% vs. 98.6%, P=0.024). A Cox regression model on 3-year restenosis highlighted female gender and hypertension to be statistically significant predictors of restenosis. Patients with a preexisting CCO did not show a significative increased risk of procedural adverse events after CAS both in the immediate and long-term follow-up, but on the long term they are more likely to experience restenosis. CCO condition should be considered always as a clinical manifestation of a more aggressive carotid atherosclerosis.

Outcomes of transcarotid artery revascularization with dynamic flow reversal in patients with contralateral carotid artery occlusion

BackgroundThe outcomes of carotid revascularization in patients with contralateral carotid artery occlusion (CCO) are controversial. CCO has been defined by the Centers for Medicare and Medicaid Services as a high-risk criterion and is used as an indication for transfemoral carotid artery stenting. With the promising outcomes associated with transcarotid artery revascularization (TCAR), we aimed to study the perioperative outcomes of TCAR in patients with CCO and to assess the feasibility of TCAR in these high-risk patients. MethodsAll patients in the Vascular Quality Initiative database who underwent TCAR with flow reversal between September 2016 and May 2019 were included. Patients with trauma, dissection, or more than two treated lesions were excluded. Univariable and multivariable logistic analyses were used to compare the primary outcome of in-hospital stroke or death after TCAR in patients with CCO and those without CCO (patent and <99% stenosis). Secondary outcomes included intraoperative neurologic changes and the individual outcomes of in-hospital stroke, death, and myocardial infarction as well as 30-day mortality. ResultsA total of 5485 TCAR cases were included, of which 593 (10.8%) had CCO. In patients with CCO, mean flow reversal time was shorter (10.1 ± 6.7 minutes vs 11.1 ± 7.8 minutes; P < .01); intraoperative neurologic changes occurred in 1% of these patients compared with 0.7% of those with patent contralateral carotid arteries (P = .43). On univariable analysis, no significant difference in in-hospital stroke or death was shown between patients with and patients without CCO (1.7% vs 1.5%; P = .65). Similarly, no significant differences were noted between the groups in terms of in-hospital death (0.7% vs 0.4%; P = .27), stroke (1.7% vs 1.2%; P = .32), and stroke/death/myocardial infarction (2.2% vs 1.8%; P = .53) as well as 30-day mortality (0.8% vs 0.6%; P = .55). The results remained statistically nonsignificant after adjustment for baseline differences between the groups; the adjusted odds ratio (OR) of in-hospital stroke/death in patients with CCO compared with those with patent contralateral carotid arteries was not significant (OR, 1.39; 95% confidence interval, 0.65-3.0; P = .40). In symptomatic patients presenting with prior stroke, CCO was associated with significantly higher odds of stroke or death (OR, 4.63; 95% confidence interval, 1.39-15.4; P = .01) compared with no CCO. On the other hand, in asymptomatic patients, no significant difference in outcomes was observed between the groups. ConclusionsIn this analysis, TCAR seems to be safe in patients with CCO. Caution should be taken in symptomatic patients with CCO and a history of prior stroke as they might have worse outcomes compared with patients with patent contralateral carotid arteries. Studies with larger sample size and longer follow-up are needed to assess the perioperative and long-term outcomes of TCAR in patients with CCO in comparison to other procedures.

Outcomes of Carotid Revascularization in Patients With Contralateral Artery Occlusion

Contralateral carotid artery occlusion (CCO) is considered a high-risk criterion for carotid endarterectomy (CEA). However, transfemoral carotid artery stenting (TfCAS) is associated with an increased risk of stroke in the perioperative period. With the promising outcomes associated with transcarotid artery revascularization (TCAR), we aimed to compare the outcomes of these three procedures in patients with CCO.

Carotid Endarterectomy With Shunt for Preoperative or Intraoperative Indication Is Associated With Increased Rate of Stroke

Carotid endarterectomy (CEA) is performed frequently both with and without the use of shunting, and previous studies have shown similar 1% to 2% rates of stroke with both techniques in asymptomatic patients. The rate of stroke when shunting is performed for a preoperative or intraoperative indication remains understudied. We aimed to evaluate the rate of stroke by shunt indication and to compare this cohort with routine shunt and no shunt cohorts in a large national registry. The Vascular Quality Initiative CEA registry was used to identify patients undergoing CEA for asymptomatic carotid stenosis from 2013 to 2019. Exclusion criteria included symptomatic patients (defined as ipsilateral transient ischemic attack or stroke within 6 months of operation), concomitant coronary intervention, proximal or distal endovascular intervention, and urgent or emergent procedures. Categorical variables were analyzed using χ2 test, and continuous variables were analyzed using analysis of variance. Multivariable logistic regression was used to evaluate demographic and perioperative predictors of stroke. There were 69,903 CEAs identified, which consisted of 33,459 without shunt, 31,711 routine shunts, 1369 shunts for preoperative indication, and 3364 shunts for intraoperative indication patients. The cohort with shunt for preoperative indication was more likely to be male, to be transferred from an outside hospital, and to have contralateral internal carotid artery (ICA) occlusion. In addition, the cohorts with shunt for indication had slightly increased procedure length, rates of re-exploration at time of initial operation, and protamine use (Table I). The rate of stroke was increased in shunt for preoperative and intraoperative indication cohorts (no shunt, 0.8%; routine shunt, 0.9%; preoperative indication, 1.8%; intraoperative indication, 1.3%; P < .01). On multivariable analysis, both shunt for preoperative indication and shunt for intraoperative indication are associated with stroke. Other perioperative and demographic variables associated with stroke include hypertension, any prior neurologic event, contralateral ICA occlusion, completion angiography, postoperative hemodynamic instability requiring intravenous medications, and re-exploration at the time of initial operation (Table II). The proportion of shunt for preoperative indication varies by region (East, 1.4%; North, 2.2%; South, 1.5%; West, 4.3%; P < .01). Regional variation is present in preoperative indication for shunt as the proportion of patients with contralateral ICA occlusion or >60% contralateral ICA stenosis varied widely (East, 55.3%; North, 62.9%; South, 52.2%; West, 47.6%; P < .01). CEA with shunt for preoperative or intraoperative indication is associated with increased rates of stroke, even in asymptomatic patients, suggesting a high-risk cohort that is poorly defined by registry data. Identifying this cohort may alter the risk-benefit ratio of the operation and inform clinical decision-making.Table IDemographic characteristics, preoperative workup, and intraoperative variablesDemographic characteristicsNo shunt (n = 33459)Routine shunt (n = 31711)Shunt: Preop indication (n = 1369)Shunt: Intraop indication (n = 3364)PAge, years (SD)70.7 (8.7)71.0 (8.8)70.4 (9.1)71.1 (8.9)<.01Sex (male)20263 (60.6)18715 (59.0)876 (64.0)1918 (57.0)<.01Comorbidities HTN29950 (89.5)28615 (90.2)1236 (90.3)3079 (91.5)<.01 CAD9092 (27.2)9061 (28.6)404 (29.5)926 (27.6)<.01 CHF3659 (10.9)3637 (11.5)157 (11.5)391 (11.6).15 Diabetes11988 (35.8)11881 (37.5)508 (37.1)1280 (38.0)<.01 Current Smoker7976 (23.8)8043 (25.4)330 (24.1)885 (26.3)<.01 ESRD352 (1.1)366 (1.2)16 (1.2)49 (1.5).16 ASA Class ≥45539 (16.6)6026 (19.0)274 (20.0)605 (18.0)<.01 Lived at Home33178 (99.2)31343 (99.1)1346 (98.4)3313 (98.5)<.01 Transfer OSH383 (1.1)341 (1.1)35 (2.6)46 (1.4)<.01Neurologic History Ipsi Neuro Event >6 months1891 (5.7)1803 (5.7)147 (10.8)214 (6.4)<.01 Ipsi Stroke >6 months1110 (3.3)1075 (3.4)103 (7.5)138 (4.1)<.01 Contra CEA5213 (15.6)5169 (16.3)156 (11.4)528 (15.7)<.01 Contra ICA Occlusion937 (2.8)1620 (5.2)370 (27.4)336 (10.3)<.01 Ipsi Stenosis ≥70%30362 (92.1)28306 (91.3)1232 (91.4)2932 (90.2)<.01 Contra Stenosis ≥70%6116 (18.6)5888 (19.0)314 (23.3)624 (19.2)<.01 Anatomic High Risk1433 (4.3)1232 (3.9)53 (3.9)147 (4.4).06Operative Factors Procedure Length (SD)114 (44)112 (42)122 (44)121 (43)<.01 Protamine23494 (70.2)21643 (68.3)985 (72.0)2581 (76.8)<.01 Patch27831 (83.3)30607 (96.5)1289 (94.2)3165 (94.1)<.01 Re-explore at Initial Operation459 (1.4)390 (1.2)19 (1.4)72 (2.1)<.01ASA, American Society of Anesthesiologists; CAD, coronary artery disease; CHF, congestive heart failure; Contra, contralateral; ESRD, end stage renal disease requiring dialysis; HTN, hypertension; ICA, internal carotid artery; Ipsi, ipsilateral; Neuro, neurologic event >6 months from procedure; OSH, outside hospital; SD, standard deviation. Open table in a new tab Table IIMultivariable logistic regression: strokeStrokeOdds ratio (OR)95% Confidence intervalPP2Y12 Inhibitor0.640.53-0.77<.01Male Gender0.810.69-0.96.02Shunt for Intraop Indication1.431.02-2.01.04Shunt for Preop Indication1.611.05-2.53.03Completion Angiogram1.691.22-2.35<.01Hypertension1.701.20-2.40<.01Contralateral ICA Occlusion1.781.34-2.38<.01Any Prior Neurologic Event1.931.63-2.29<.01Postop IV Medication for Hemodynamic Instability3.432.91-4.05<.01Re-explore at Initial Operation9.5411.31-17.08<.01 Open table in a new tab

Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients

Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I2 test. I2>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I2=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I2=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I2=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I2=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I2=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I2=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I2=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I2=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I2=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I2=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.

Does contralateral carotid artery occlusion affect the clinical and long-term outcomes of carotid artery stenting?

IntroductionCarotid artery stenting (CAS) has been used with increasing frequency in recent years as an alternative to surgery. Contralateral carotid occlusion (CCO) is present in approximately 2.3% to 25% of cases of revascularised carotid atherosclerotic stenosis. We aimed to compare the outcomes of 30-day, 6-month and 1-year stroke, transient ischaemic attack (TIA), death and myocardial infarction (MI) in patients with and without CCO who underwent CAS in our clinic.Material and methodsThe study was conducted with 288 consecutive patients who underwent CAS between September 2010 and June 2018. Patients with carotid stenting were divided into two groups: with (48 patients) and without CCO (240 patients).ResultsTotal mortality (2.08% vs. 2.08% p = 1), stroke (2.08% vs. 0.83%, p = 0.43), TIA (0% vs. 0.83%, p = 0.52), MI (0% vs. 0%), and composite outcome (4.17% vs. 3.33%, p = 0.77) at 30 days were not significantly different between CCO and non-CCO groups. Also there was no statistically significant difference between the two groups in terms of the 6-month and 1-year outcomes (p > 0.05).ConclusionsThere was no difference between 30-day, 6-month and 1-year non-fatal MI, TIA, ischaemic stroke and mortality in the comparison of patients with and without CCO who underwent CAS. The outcomes were similar in terms of age and symptoms, and these data should be supported by prospective multicenter studies.

Mid-term Outcomes of the (Roadster) Multi-center Trial of Transcarotid Stenting With Dynamic Flow Reversal

Introduction - The Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial has introduced a novel transcarotid neuroprotection system (ENROUTE Transcarotid NPS; Silk Road Medical Inc, Sunnyvale, Calif). Perioperative results demonstrated that the use of EROUTE Transcarotid NPS was safe and effective. Overall 30-day stroke rate was 1.4% which was the lowest reported in any clinical trial for carotid artery stenting. We now present the mid-term results to evaluate the durability of transcarotid carotid artery revascularization (TCAR). Methods - This study is a prospective, single-arm clinical trial. Current enrollment occurs in 14 centers. Primary endpoints were incidence rates of ipsilateral stroke and death at one-year following (TCAR). The occurrence of stroke was ascertained by an independent clinical event committee. Results - Overall, 286 patients were enrolled (lead-in phase: 67, pivotal phase: 141 and extended access: 78 patients). Of those, 164 were included in the long-term follow-up (112 patients from the pivotal phase and 52 from the extended access). Mean age was 73.9 years (range: 42.1-91.3years). Patients of age 75 years and older were 43.3% of the cohort. 34.8% of patients were females, 92.7% were Caucasians and 5.5% were African-American. Most patients were asymptomatic (79.9%). Patients with anatomical high-risk factors for carotid artery endarterectomy (CEA) were eligible for ROADSTER trial. Those anatomical risk factors were distributed as follows: contralateral carotid artery occlusion was reported in 11.0% of patients, tandem stenosis of greater than 70% was found in 1.8% of patients, high cervical carotid artery stenosis contributed to 25.0% of TCAR indications, restenosis after CEA was found in 25.6%, while bilateral stenosis requiring treatment occurred in 4.3% and hostile neck was the indication of TCAR in 14.6% of cases. two-vessel coronary artery disease was reported in 14.0% of the participants and severe left ventricular dysfunction (LEVF<30%) was reported in 3 (1.8%) patients. In general, anatomical high-risk factors took place in 43.3% while clinical high-risk factors were 29.9%. Both subsets of factors were present in 26.8%. At one-year follow-up, ipsilateral stroke incidence rate was 0.6% and the overall mortality rate was 3.7%. The one-year risk of stroke found in this study is the lowest to date to be reported in any FDA approved carotid stents (Figure). Conclusion - Transcarotid carotid artery revascularization with dynamic flow reversal had previously shown favorable 30-day perioperative outcomes. This excellent performance seems to extend to one year following TCAR as illustrated in this analysis. The promising results from the ROADSTER trial might stem from the novel cerebral protection provided by the ENROUTE Transcarotid NPS in comparison to distal protection devices. The trans-cervical approach circumvents aortic arch manipulation that takes place through the transfemoral approach. TCAR offers a potentially safe option for patients who are deemed to be high-risk for CEA.

Results of carotid endarterectomy in patients with contralateral internal carotid artery occlusion from the Mid-America Vascular Study Group and the Society for Vascular Surgery Vascular Quality Initiative

ObjectiveCarotid endarterectomy (CEA) is among the most commonly performed vascular procedures. Some have suggested worse outcomes with contralateral internal carotid artery (ICA) occlusion. We compared patients with and patients without contralateral ICA occlusion using the Society for Vascular Surgery Vascular Quality Initiative database. MethodsDeidentified data were obtained from the Vascular Quality Initiative. Patients with prior ipsilateral or contralateral CEA, carotid stenting, combined CEA and coronary artery bypass graft, or <1-year follow-up were excluded, yielding 1737 patients with and 45,179 patients without contralateral ICA occlusion. Groups were compared with univariate tests, and differences identified in univariate testing were entered into multivariate models to identify independent predictors of outcomes and in particular whether contralateral ICA occlusion is an independent predictor of outcomes. ResultsPatients with contralateral ICA occlusion were younger and more likely to be smokers; they were more likely to have chronic obstructive pulmonary disease, preoperative neurologic symptoms (56% vs 47%), nonelective CEA (16% vs 13%), and shunt placement (75% vs 53%; all P < .001). The 30-day ipsilateral stroke risk was 1.3% with vs 0.7% without contralateral ICA occlusion (P = .004). The 30-day and 1-year survival estimates were 99.0% ± 0.5% and 94.1% ± 1.1% with vs 99.6% ± 0.1% and 96.0% ± 0.2% without contralateral ICA occlusion (log-rank, P < .001). Logistic regression analysis identified prior neurologic event (P = .046), nonelective surgery (P = .047), absence of coronary artery disease (P = .035), and preoperative angiotensin-converting enzyme inhibitor use (P = .029) to be associated with 30-day ipsilateral stroke risk, but contralateral ICA occlusion remained an independent predictor in that model (odds ratio, 2.29; P = .026). However, after adjustment for other factors (Cox proportional hazards), risk of ipsilateral stroke (including perioperative) during follow-up was not significantly greater with contralateral ICA occlusion (hazard ratio, 1.21; P = .32). Results comparing propensity score-matched cohorts mirrored those from the larger data set. ConclusionsThis study demonstrates likely clinically insignificant differences in early stroke or death in comparing CEA patients with and those without contralateral ICA occlusion. After adjustment for other factors, contralateral ICA occlusion was not associated with a greater risk of ipsilateral stroke (including perioperative) in longer follow-up. Mortality was greater with contralateral ICA occlusion, and this difference was more pronounced at 1 year despite younger age of the contralateral ICA occlusion group. CEA risk remains low even in the presence of contralateral ICA occlusion and appears to be explained at least in part by other factors. CEA should still be considered appropriate in the face of contralateral ICA occlusion.

In-Hospital Outcomes of Transcarotid Artery Revascularization With Dynamic Flow Reversal in Patients With Contralateral Carotid Artery Occlusion

In-Hospital Outcomes of Transcarotid Artery Revascularization With Dynamic Flow Reversal in Patients With Contralateral Carotid Artery Occlusion

IP105. Shunting in Patients With Contralateral Carotid Artery Occlusion During Carotid Endarterectomy Does Not Improve Perioperative Risk of Stroke or Death

Controversy exists regarding outcomes in patients with contralateral carotid artery occlusion (CCO) when undergoing carotid endarterectomy (CEA). We hypothesized that patients with CCO undergoing CEA were at higher risk for stroke and mortality. We used a contemporary national database to evaluate perioperative outcomes in patients with and without CCO undergoing CEA. The American College of Surgeons National Surgical Quality Improvement Program targeted vascular database was queried for patients who underwent CEA between 2011 and 2017. Those included in the CCO cohort had preoperative ultrasound and/or angiographic evidence of CCO. Patient demographics, operative variables, and outcomes including stroke and 30-day mortality were compared with descriptive statistics. Multivariable regression models were used for analysis. During the 8-year study period 24,781 patients underwent CEA. CCO was present in 950 patients (3.8%). Patients with CCO were younger (69.7 years vs 71.2 years; P < .001); more often male (70% vs 61%; P < .001); more often smokers (37% vs 26%; P < .001); less likely to be diabetic (28% vs 31%; P = .02); and more likely to have chronic obstructive pulmonary disease (13% vs 10%; P = .007) when compared with those without CCO. Patients with CCO were more likely to be asymptomatic from their ipsilateral carotid disease (60% vs 56%; P = .02), but more frequently had severe stenosis (66% vs 65%; P < .001). Patients with CCO had higher perioperative morbidity (19% vs 15%; P = .003), 30-day mortality (1.5% vs 0.67%; P = .007) and stroke rate (2.8% vs 1.7%; P = .01) when compared with those without CCO. When controlled for age, sex, shunt use, patch closure, asymptomatic status, ipsilateral transient ischemic attack, diabetes, and congestive heart failure, the risk of stroke and death in patients with CCO was higher (odds ratio, 3.05; 95% confidence interval [CI], 1.16-6.66; P = .01) than those without CCO, as was the risk of stroke or death (odds ratio, 1.5; 95% CI, 1.06-2.13; P = .02). When evaluating the efficacy of shunting in individuals with CCO, and controlling for age, anesthesia type, patch closure, asymptomatic status, ipsilateral transient ischemic attack, diabetes, and congestive heart failure, the risk of death in patients with CCO who underwent shunting was 4. -times higher (95% CI, 1.21-19.30; P = .03) than in patients who did not have an intraoperative shunt. The risk of stroke and death in patients with CCO is higher when compared with those without CCO. Additionally, the risk of death in patients with CCO is elevated in patients undergoing intraoperative shunting. Careful consideration and discussion of the risks of CEA in patients with CCO must occur. Additional studies must be performed to confirm these results.

Comparison of postoperative results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid artery occlusion: A meta-analysis.

Objectives The purpose of this study was to conduct a meta-analysis to systematically compare the safety and efficacy of carotid endarterectomy and carotid artery stenting in contralateral carotid occlusion patients who needed reperfusion. Methods This study retrieved potential academic articles comparing results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid occlusion from the MEDLINE database, the PubMed database the EMBASE database, and the Cochrane Library from January 1990 to May 2018. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. Results Four retrospective cohort study involving 6252 patients with contralateral carotid occlusion were included in our meta-analysis. During 30-day follow-up, there is significant difference in post-procedure mortality (odds ratio (OR) = 0.476, 95% confidence interval (CI) (0.306–0.740), P = 0.001); no significant differences are not found in post-procedure stroke (risk difference (RD) = 0.002, 95%CI (–0.007 to 0.011); P = 0.631), myocardial infarction (RD = 0.003, 95%CI (–0.002 to 0.008); P = 0.301), and transient cerebral ischemia (RD = 1.059, 95%CI (–0.188 to 5.964); P = 0.948). Conclusions Carotid endarterectomy was associated with a lower incidence of mortality compared to carotid artery stenting for patients with contralateral carotid occlusion. Regarding stroke, myocardial infarction, and transient ischemic attack, there was no significant difference between the two groups. More randomized controlled trials and prospective cohorts are necessary to help further clarify the ideal approach for these patients.