Outcomes of carotid revascularization procedures in symptomatic patients according to preoperative symptoms, timing from symptoms, and modified Rankin Scale Score

Stroke remains a common cause of death globally, and ischemic strokes make up 87% of all strokes. Carotid disease is implicated in 10-15% of ischemic strokes, and the treatment of choice has historically been a carotid endarterectomy (CEA), first described in the 1950s. However, recent advanced techniques such as transfemoral carotid artery stenting (tfCAS), introduced in the 1990s, and transcarotid artery revascularization (TCAR), introduced in the 2010s, have altered this landscape. In this article, we explore the history of the different modalities and focus on outcomes in symptomatic patients based on their preoperative symptoms, timing from symptoms, and stroke severity using the modified Rankin Scale (mRS) Score. We conducted a focused overview of articles that reported outcomes of the three modalities based on preoperative symptom status, timing of symptoms, and mRS Score. When patients were stratified on pre-procedural symptoms (stroke, hemispheric TIA, ocular TIA, or formerly symptomatic) and timing (recent defined as <180 days from event), patients with a recent stroke had the highest 30-day stroke/death rates irrespective of modality. Further, higher preoperative mRS scores were significantly associated with in-hospital stroke/death rates. The highest rates of in-hospital stroke/death occurred in patients undergoing revascularization within the first two days, consistent with SVS guidelines that recommend delaying revascularization until days two to fourteen post-event. There is no consensus on the ideal carotid revascularization procedure; however, it is prudent to consider the patient's presenting symptoms, timing of symptoms, and potential disability from stroke in deciding between the different modalities.