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

Christina L. Cui, MD, MAS; Hanaa Dakour-Aridi, MD; Jinny J. Lu, MD; Kevin S. Yei, BS; Marc L. Schermerhorn, MD; Mahmoud B. Malas, MD, MHS

Disclosures

Stroke. 2022;53(1):100-107. 

In This Article

Abstract and Introduction

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.

Introduction

Surgical intervention is superior to medical management for the treatment of symptomatic carotid artery stenosis.[1] Early intervention can prevent recurrent stroke or transient ischemic attack (TIA), which may be as high as 20% in the first 72 hours after onset of symptoms.[2] Early intervention is also associated with long-term benefits. In a pooled analysis of over 2000 patients from the North American Symptomatic Carotid Endarterectomy Trial and the European Surgical Carotid Trial, patients receiving carotid endarterectomy (CEA) within 2 weeks of onset of symptoms had 19% absolute risk reduction in the risk of recurrent stroke.[3] However, CEA benefits decreased when intervention was delayed. Patients undergoing revascularization at 12 weeks or later after the onset of symptoms had no demonstrable benefit.

Despite the desire to perform early revascularization, evidence suggests that CEA within 48 hours of symptoms is associated with increased perioperative risks. In a study from the Swedish National Registry, patients undergoing CEA within 48 hours had 4× the odds of 30-day stroke or death when compared with patients undergoing CEA between 3 and 7 days.[4] Similar results were noted in the National Vascular Registry of the United Kingdom,[5] smaller retrospective studies,[6] and other prospective registries.[7] Outside of this 48-hour window, however, early and delayed revascularization, either at 7 or 14 days, had comparable safety profiles. Given that the perioperative risks of performing CEA between 3 and 14 days after symptoms are relatively low compared with the risk of recurrent stroke, revascularization after 48 hours from the onset of symptoms may represent ideal timing for carotid revascularization. Current guidelines from the Society of Vascular Surgery and the European Society of Vascular Surgery recommend CEA within 2 weeks for patients presenting with mild or moderate neurological deficits.[8,9]

Most studies on timing of carotid revascularization for symptomatic patients have focused on CEA. In general, transfemoral carotid artery stenting (TFCAS) has higher perioperative stroke risk when compared with CEA.[10] Studies on TFCAS timing have found that this elevated perioperative risk is more pronounced within the immediate time period after onset of symptoms. A study from the Carotid Stenosis Trialists' Collaboration combining data from four large randomized clinical trials found that TFCAS has anywhere between 6 and 8× higher periprocedural risk within the first seven days after symptoms compared with 2× higher periprocedural risk in procedures delayed beyond seven days.[11] These findings led to CEA being considered the recommended intervention for early symptoms.[8]

A novel method of carotid artery stenting is transcarotid artery revascularization (TCAR) with flow reversal. While prospective randomized control trials have not been completed, it is thought that TCAR's avoidance of the aortic arch and the use of flow reversal have given TCAR comparative outcomes to CEA and half the perioperative risk of stroke/death when compared with TFCAS.[12–15] To date, no studies have looked the outcomes of all 3 carotid revascularization procedures when performed at different times after symptoms occur. Given that TCAR overcomes many of the pitfalls seen with TFCAS and uses carotid clamping similar to CEA, it is possible that TCAR has comparable timing profiles to CEA. The purpose of this study is to compare perioperative outcomes after TCAR, TFCAS, and CEA among patients undergoing urgent, early, and delayed revascularization for symptomatic carotid artery stenosis.

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