In-Hospital Outcomes of Urgent, Early, or Late Revascularization for Symptomatic Carotid Artery Stenosis

Abstract

Background and Purpose: Advancements in carotid revascularization have produced promising outcomes in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization procedures after symptomatic presentation remains unclear. The purpose of this study is to compare in-hospital outcomes of transcarotid artery revascularization (TCAR), transfemoral carotid stenting (TFCAS), or carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. Methods: This is a retrospective cohort study of United States patients in the vascular quality initiative. All carotid revascularizations performed for symptomatic carotid artery stenosis between September 2016 and November 2019 were included. Procedures were categorized as urgent (0–2 days after most recent symptom), early (3–14 days), or late (15–180 days). The primary outcome of interest was in-hospital stroke and death. Secondary outcomes include in-hospital stroke, death, and transient ischemic attacks. Multivariable logistic regression was used to compare outcomes. Results: A total of 18 643 revascularizations were included: 2006 (10.8%) urgent, 7423 (39.8%) early, and 9214 (49.42%) late. Patients with TFCAS had the highest rates of stroke/death at all timing cohorts (urgent: 4.0% CEA, 6.9% TFCAS, 6.5% TCAR, P =0.018; early: 2.5% CEA, 3.8% TFCAS, 2.9% TCAR, P =0.054; late: 1.6% CEA, 2.8% TFCAS, 2.3% TCAR, P =0.003). TFCAS also had increased odds of in-hospital stroke/death compared with CEA in all 3 groups (urgent adjusted odds ratio [aOR], 1.7 [95% CI, 1.0–2.9] P =0.03; early aOR, 1.6 [95% CI, 1.1–2.4] P =0.01; and late aOR, 1.9 [95% CI, 1.2–3.0] P =0.01). TCAR and CEA had comparable odds of in-hospital stroke/death in all 3 groups (urgent aOR, 1.9 [95% CI, 0.9–4], P =0.10), (early aOR, 1.1 [95% CI, 0.7–1.7], P =0.66), (late aOR, 1.5 [95% CI, 0.9–2.3], P =0.08). Conclusions: CEA remains the safest method of revascularization within the urgent period. Among revascularization performed outside of the 48 hours, TCAR and CEA have comparable outcomes.

Dual Antiplatelet Alternatives are Associated With Increased Stroke and Death After Transcarotid Revascularization

“…The definitions of these events and additional variables are established by the VQI and have been described in detail elsewhere. 10…”

The Three Most Discussed Questions in Carotid Artery Surgery. Review of Russian and Foreign Studies in the Last Five Years

“…Cui C.L. et al проанализировали результаты КАС и КЭЭ в разные сроки от манифестации ОНМК у 18 643 пациентов [85]. Наибольшие показатели смертельных исходов + ОНМК были зафиксированы после эндоваскулярной процедуры: 4,0% в группе КЭЭ и 6,9% в группе КАС, р=0,01 -через 0-2 дня после развития ИИ; 2,5% в группе КЭЭ и 3,8% в группе КАС, р=0,05через 3-14 дней после развития ИИ; 1,6% в группе КЭЭ и 2,8% в группе КАС, р=0,003 -через 15-180 дней после развития ИИ [85].…”

Transcarotid Revascularization Timing and Early Postoperative Outcomes in Symptomatic Patients

“…8 However, to the best of our knowledge, similar TCAR studies have only categorized "early" patients as having been operated on between 2-14 days. 2,10 Extrapolation of these CEA results have, therefore, affected the timing of TCAR after neurologic insult. However, physiology of cerebral flow reversal may be dissimilar to carotid shunting or clamping observed with CEA.…”

“…Transcarotid artery revascularization (TCAR) is a hybrid carotid procedure utilizing cerebral flow reversal to mitigate intraoperative plaque embolization during the course of carotid stenting. 1 While carotid endarterectomy (CEA) continues to be the gold-standard when it comes to carotid surgery, TCAR has been shown to be comparable 2 —or favorable 3,4 —in nonrandomized samples. This flow reversal technique was deemed safe and effective 5,6 and, thus, TCAR became commercially available in 2015.…”

“…8 However, to the best of our knowledge, similar TCAR studies have only categorized “early” patients as having been operated on between 2-14 days. 2,10…”