Outcomes of Redo vs Primary Carotid Endarterectomy in the TCAR Era

Outcomes following redo-CEA (rCEA) have been shown to be worse than those after primary CEA (pCEA). Additional research has shown that outcomes are better with TCAR for restenosis after CEA compared with rCEA and tfCAS; however, some patients are not eligible for TCAR or tfCAS. Given the increasing utilization of endovascular techniques, this study aims to evaluate changes in outcomes of rCEA vs pCEA before and after the approval of TCAR by the FDA in 2015. All patients between 2003 and 2023 who underwent CEA in the VQI were included and categorized as pCEA or rCEA. Cochrane-Armitage trend testing was used to examine trends in the proportion of rCEA compared to pCEA, and Mann-Kendall trend testing was used for perioperative outcomes. Multivariable logistic regression analysis was used to compare in-hospital stroke/death, stroke, death, and stroke/death/MI following rCEA versus pCEA after stratifying patients into two cohorts: 2003-2015 and 2016-2023 (before and after the introduction of TCAR). Subgroup analysis was performed in symptomatic and asymptomatic patients within both time cohorts. Of 198,150 patients undergoing CEA, 98.4% were pCEA and 1.6% were rCEA. During the study period, the proportion of rCEA in the VQI decreased from 2.3% to 1.0% (P < .001) (Fig 1). Trend testing of individual outcomes showed an increase in the stroke/death rate following rCEA over time (P = .019) (Fig 1) despite an improvement in the death rate. Interestingly while CNI remained higher for rCEA vs pCEA overall, the proportion of CNI decreased over time (P = .001). A similar pattern was observed with length of stay. From 2003-2015, patients undergoing rCEA had higher odds of stroke/death compared to pCEA (2.4% vs 1.2%; aOR, 1.81; 95% CI, 1.14-2.73; P = .007). A subgroup analysis showed that the difference in stroke/death rates persisted only in asymptomatic patients (2.3% vs 1.1%; aOR, 2.03; 95% CI, 1.19-3.25; P = .006); however, there was no difference in symptomatic patients (3% vs 2.0%; aOR, 1.37; 95% CI, 0.51-3.01; P = .50). In the post TCAR period from 2016-2023, patients undergoing rCEA had higher odds of stroke/death compared to pCEA (3.1% vs 1.3%; aOR, 2.45; 95% CI, 1.85-3.18; P < .001), and the association was similar in asymptomatic patients (1.9% vs 1.0%; aOR, 1.95; 95% CI, 1.29-2.82; P < .001), and larger in symptomatic patients (6.3% vs 2.0%; aOR, 3.23; 95% CI, 2.17-4.64; P < .001) (Table I). The proportion of redo-CEAs done yearly in the USA has been decreasing as endovascular options became available. As the rate of rCEA has decreased, outcomes have been worsening, with an increasing stroke/death rate seen over time, driven primarily by worse outcomes in symptomatic patients. With a stroke death rate of over 6%, these patients are unlikely to benefit from rCEA and would be better served with TCAR or tfCAS if eligible or aggressive medical management.Table IOutcomes of redo CEA vs primary in pre vs post TCAR eraOutcome2003-20152016-2023Unadjusted ratesAdjusted outcomesUnadjusted ratesAdjusted outcomesRedo CEA vs primary CEARedo CEA vs primary CEArCEA ratepCEA rateaOR95% CIP-valuerCEA ratepCEA rateaOR95% CIP-value(n = 1287)(n = 58,288)(n = 1899)(n = 136,676)Death1.00%0.40%2.791.31-5.26.0030.90%0.30%2.261.32-3.60.001Stroke2.00%0.90%1.811.09-2.83.0152.50%1.00%2.581.89-3.43<.001Stroke/death2.40%1.20%1.811.14-2.73.0073.10%1.30%2.451.85-3.18< .001Stroke/death/MI3.40%2.00%1.651.12-2.35.0074.20%1.80%2.321.83-2.91<.001Cranial nerve injurya3.5%3.3%1.050.77-1.40.702.4%2.7%1.160.87-1.51.30Post-op length of stay2.652.14---2.532.04---Asymptomatic only(n = 1085)(n = 47,231)(n = 1408)(n = 96,785)Death1.00%0.30%3.671.59-7.37< .0010.60%0.30%2.131.00-3.95.029Stroke1.80%0.90%1.881.01-3.19.031.60%0.80%2.061.30-3.09<.001Stroke/death2.30%1.10%2.031.19-3.25.0061.9%1.00%1.951.29-2.82< .001Stroke/death/MI3.30%1.80%1.751.12-2.62.0093.20%1.50%2.141.56-2.85<.001Cranial nerve injurya3.6%3.4%1.070.76-1.46.702.8%2.2%1.270.90-1.72.15Post-op length of stay2.062.55---2.411.85---Symptomatic only(n = 202)(n = 11,057)(n = 491)(n = 39,891)Death1.00%0.50%1.350.19-5.13.701.60%0.50%2.531.12-4.92.013Stroke3.00%1.70%1.70.64-3.75.205.10%1.60%3.362.16-4.98<.001Stroke/death3.0%2.00%1.370.51-3.01.506.30%2.00%3.232.17-4.64<.001Stroke/death/MI4.0%2.60%1.390.60-2.75.46.90%2.50%2.671.83-3.77<.001Cranial nerve injurya3.2%3.0%0.930.37-1.94.902.8%2.6%0.940.51-1.57.80Post-op length of stay3.142.48---2.862.51---Bold text denotes P < .05 for unadjusted outcome rates.aAdjusted for age, race, sex, BMI, HTN, COPD, CAD, CHF, smoking, urgency, stenosis >80% and symptomatic presentation.bCNI OR unadjusted. Open table in a new tab