Risk of intracranial hemorrhage after carotid artery stenting versus endarterectomy: a population-based study

Abstract

OBJECTIVE Intracranial hemorrhage (ICH) associated with cerebral hyperperfusion syndrome is a rare but major complication of carotid artery revascularization. The objective of this study was to compare the rate of ICH after carotid artery stenting (CAS) with that after endarterectomy (CEA). METHODS The authors performed a retrospective population-based cohort study of patients who underwent carotid artery revascularization in the province of Ontario, Canada, between 2002 and 2015. The primary outcome was the rate of ICH that occurred within 90 days after carotid artery intervention among patients who underwent CAS versus that of those who underwent CEA. The authors used inverse probability of treatment weighting and propensity scores to account for selection bias. In sensitivity analyses, patients who had postprocedure ischemic stroke were excluded, and the following subgroups were examined: patients with symptomatic and asymptomatic carotid artery stenosis, patients treated between 2010 and 2015, and patients aged ≥ 66 years (to account for antiplatelet and anticoagulant use). RESULTS A total of 16,688 patients underwent carotid artery revascularization (14% CAS, 86% CEA). Patients with more comorbid illnesses, symptomatic carotid artery stenosis, or cardiac disease and those who were taking antiplatelet agents or warfarin before surgery were more likely to undergo CAS. Among the overall cohort, 80 (0.48%) patients developed ICH within 90 days (0.85% after CAS, 0.42% after CEA). The 180-day mortality rate after ICH in the overall cohort was 2.7%, whereas the 180-day mortality rate among patients who suffered ICH was 42.5% (40% for CAS-treated patients, 43.3% for CEA-treated patients). In the adjusted analysis, patients who underwent CAS were significantly more likely to have ICH than those who underwent CEA (adjusted OR 1.77; 95% CI 1.32-2.36; p < 0.001). These results were consistent after excluding patients who developed postprocedure ischemic stroke (adjusted OR 1.90; 95% CI 1.41-2.56) and consistent among symptomatic (adjusted OR 1.74; 95% CI 1.16-2.63) and asymptomatic (adjusted OR 1.75; 95% CI 1.16-2.63) patients with carotid artery stenosis, among patients treated between 2010 and 2015 (adjusted OR 2.21; 95% CI 1.45-3.38), and among the subgroup of patients aged ≥ 66 years (adjusted OR 1.53; 95% CI 1.05-2.24) after adjusting for medication use. CONCLUSIONS CAS is associated with a rare but higher risk of ICH relative to CEA. Future research is needed to devise strategies that minimize the risk of this serious complication after carotid artery revascularization.

Comparison of Long Term Prognosis between Carotid Endarterectomy versus Stenting; A Korean Population-Based Study Using National Insurance Data

“…The incidence of ischemic stroke after carotid revascularization in this study was higher than those of previous studies, but the long-term mortality was similar. The incidence of cerebral hemorrhage after carotid stenting was reported about 0.85–4.4% from previous population-based studies and it was 2–6 fold higher among CAS relative to CEA [21,22]. Although this study was based on long-term follow-up, the incidence of cerebral hemorrhage and the risk of CAS were similar to those of the previous studies.…”

Comparison of Outcomes in Elective Endovascular Aortic Repair vs Open Surgical Repair of Abdominal Aortic Aneurysms

“…Ontario administrative data are routinely used for population-level research and have previously been thoroughly described and validated. 19,20,21,22 The specific databases used for this study are described in eTable 1 in the Supplement. This study was approved by the research ethics board at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada, and the requirement for informed consent was waived owing to the use of deidentified secondary data.…”

Update on cerebral hyperperfusion syndrome

“…This conclusion was contradictory to that of a large cohort study that compared 2341 cases of CAS with 14 347 cases of CEA, in which patients who had undergone CAS were significantly more likely to have ICH than those who had undergone CEA (0.85% vs 0.42%). 17 However, patients referred for endovascular treatment comprised a high risk cohort of suboptimal candidates for CEA in many CAS series. This difference in patient populations may partially explain the difference in CHS incidence and severity.…”

“…This conclusion was contradictory to that of a large cohort study that compared 2341 cases of CAS with 14 347 cases of CEA, in which patients who had undergone CAS were significantly more likely to have ICH than those who had undergone CEA (0.85% vs 0.42%). 17…”