Risk of Stroke or Death Is Associated With the Timing of Carotid Artery Stenting for Symptomatic Carotid Stenosis: A Secondary Data Analysis of the German Statutory Quality Assurance Database

Abstract

Background--Subgroup analyses from randomized trials indicate that the time interval between the neurologic index event and carotid artery stenting is associated with periprocedural stroke and death rates in patients with symptomatic carotid stenosis. The aim of this article is to analyze whether this observation holds true under routine conditions in Germany.Methods and Results--Secondary data analysis was done on 4717 elective carotid artery stenting procedures that were performed for symptomatic carotid stenosis. The patient cohort was divided into 4 groups according to the time interval between the index event and intervention (group I 0-2, II 3-7, III 8-14, and IV 15-180 days). Primary outcome was any in-hospital stroke or death. For risk-adjusted analyses, a multilevel multivariable regression model was used. The in-hospital stroke or death rate was 3.7% in total and 6.0%, 4.4%, 2.4%, and 3.0% in groups I, II, III, and IV, respectively. Adjusted analysis showed a decreased risk for any stroke or death in group III, a decreased risk for any major stroke or death in groups III and IV, and a decreased risk for any death in groups II and III compared to the reference group I.Conclusions--A short time interval between the neurologic index event and carotid artery stenting of up to 7 days is associated with an increased risk for stroke or death under routine conditions in Germany. Although results cannot prove causal relationships, carotid artery stenting may be accompanied by an increased risk of stroke or death during the early period after the index event. ( J Am Heart Assoc. 2018;7:e007983.

Safety and efficacy of symptomatic carotid artery stenting performed in an emergency setting

“…15 Tsantilas et al found a complication rate of 4.65% in the patients treated with CAS within the first week and a 3.9% rate in patients treated between 8 to 180 days. 4 These results are comparable to the rate of minor complications found in our elective CAS group (4.8%), and lower than our emergency CAS group (9%). This higher proportion in our emergency CAS group might be due to the higher rates of tandem occlusions and ipsilateral carotid occlusions, which demonstrated to be an independent risk factor for the composite of primary and secondary outcomes in the multivariate analysis.…”

“…Regarding CAS timing, Song et al and Tsantilas et al found that early symptomatic CAS (within two weeks and one week, respectively) had more events (stroke or death) within 30 days post-procedure and during hospitalization than the delayed group (>2 weeks and 8 to 180 days, respectively). 4,5 In contrast, other studies supported early CAS within their 7 or 15 days cut-off, showing no significant differences in stroke or deaths at 30 days. 6,7,17,18 A recent prospective study compared CAS to CEA when performed within the first 48 hours and found similar rates of stroke or any cause of death within 30 days (5.1% vs. 4.9%, respectively).…”

“…We executed multivariable logistic regression models to assess the risk factors associated with the composite of primary and secondary outcomes. We built our multivariable model using previously wellcharacterized predictors such as sex and age 4,5 in combination with significant variables found to be associated with CAS in our univariate analysis (p < 0.05). Adjusted odds ratios (OR's) and 95% confidence intervals were calculated as the measure of association.…”

“…3 The Secondary Data Analysis of the German Statutory Quality Assurance Database found that a short time interval between the neurologic index event and CAS of up to 7 days is associated with an increased risk for stroke or death under routine conditions. 4 In the contrary, Song et al found that there were no differences in late events (ipsilateral stroke or any death from 31 days to 1 year from CAS) between early ( 2 weeks) and delay (>2 weeks) CAS. 5 Studies supporting early revascularization reported promptly timing carried no additional risks compared with delayed CAS up to 90 days.…”