Outcomes Following Carotid Revascularization in Patients with Prior Carotid Artery Stenting

The outcomes of carotid revascularization in patients with prior carotid artery stenting remain understudied. In addition, prior research has not reported the outcomes after transcarotid artery revascularization in patients with previous carotid artery stenting. Using the Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA following prior ipsilateral carotid artery stenting. We included covariates such as age, race, sex, BMI, comorbidities (hypertension, diabetes, prior CAD, prior CABG/PCI, CHF, renal dysfunction, smoking, COPD, anemia), symptom status, urgency, ipsilateral stenosis, contralateral occlusion, into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability-weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality and cranial nerve injury (CNI) following TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. We identified 2383 patients undergoing revascularization following prior ipsilateral carotid stenting (TCAR: 33%, tfCAS: 52%, CEA: 15%). Compared with TCAR, tfCAS was associated with a trend towards higher stroke/death (tfCAS vs TCAR: 2.3% vs 1.0%; OR, 2.3; 95% CI, 0.98-5.1; P = .055 (Table 1). On the other hand, compared with TCAR, CEA patients had similar odds of stroke/death (CEA vs TCAR: 1.1% vs 1.0%; OR, 1.1; 95% CI, 0.29-3.9; P = .92). However, CEA was associated with substantially higher odds of postoperative MI (3.2% vs 0.4%; OR, 8.9; 95% CI, 1.8-43; P = .008), stroke/death/MI (4.3% vs 1.4%; OR, 3.2; 95% CI, 1.2-8.9; P = .030), and CNI (4.2% vs 0.3%; OR, 13; 95% CI, 3.6-50; P < .001). We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%) (Fig 1), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001). In patients with prior ipsilateral carotid artery stenting, tfCAS was associated with higher stroke/death compared with TCAR, while stroke/death after CEA was comparable with TCAR. However, CEA was associated with higher postoperative MI and CNI. In line with the post-procedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.TableOutcomes following carotid revascularization in patients with prior ipsilateral carotid stenting after inverse-probability weightingAdjusted ratestfCAS vs TCARCEA vs TCARTCAR (n = 790)tfCAS (n = 1233)CEA (n = 360)aOR [95% CI]P-valueaOR [95% CI]P-valueIn-hospital stroke0.9%1.8%0.4%1.9 [0.80-4.6].160.43 [0.05-3.6].43In-hospital death0.3%0.8%0.7%2.5 [0.67-9.2].172.2 [0.42, 12].35Stroke/death1.0%2.3%1.1%2.2 [0.98-5.1].0551.1 [0.29-3.9].92Postoperative MI0.4%0.4%3.2%0.96 [0.22-4.3].978.9 [1.8-43].008Stroke/death/MI1.4%2.4%4.3%1.7 [0.84-3.6]0.143.2 [1.2-8.9].03030-day mortality0.8%1.8%0.9%2.2 [0.94-5.4].0701.1 [0.28-3.9].94Cranial nerve injury0.3%0.0%4.2%--13 [3.6-50]<.001 Open table in a new tab