Carotid Bypass: Insights from a Real World Multicentre French Cohort

OBJECTIVE: The aim of this study was to assess the use and early and midterm outcomes of carotid bypass surgery in a large, multicentre, real world cohort. METHODS: This retrospective multicentre study included consecutive patients who underwent carotid bypass surgery in 12 French centres between January 2010 and October 2023. The primary endpoint was the thirty day composite of any stroke and or death. Secondary endpoints included procedure related complications, midterm primary patency, and ipsilateral ischaemic stroke. RESULTS: Four hundred and fifty-nine patients were analysed (mean age 70 years; 80.4% men). Carotid bypass was performed intra-operatively as a bailout during carotid endarterectomy in 51.2% of cases and was scheduled pre-operatively in 48.8% for complex carotid lesions, including re-stenosis, long lesions, associated aneurysms, or post-radiation stenosis. The primary endpoint occurred in 5.8% (27 of 459), including stroke in 4.3% and death in 2.8%; 5.4% of asymptomatic and 6.9% of symptomatic patients experienced the primary endpoint. Prosthetic grafts were used in 69.7% of cases and autologous vein grafts in 30.1%. Use of prosthetic material (odds ratio [OR] 5.35, 95% confidence interval [CI] 1.19 - 24.14; p = .046) and diabetes (OR 2.35, 95% CI 1.01 - 5.73; p = .048) were independently associated with increased risk of thirty day stroke and or death, whereas statin therapy was protective (OR 0.26, 95% CI 0.11 - 0.66; p = .005). During follow up (median 2.7 years, interquartile range 0.8, 5.7), cumulative Kaplan-Meier estimate of primary patency was 100%, 98.2%, and 97.1% at one, three, and five years, respectively. CONCLUSION: In this multicentre cohort, carotid bypass surgery was used in selected complex situations and appeared to be associated with a potentially unacceptable excess risk in asymptomatic patients. In symptomatic patients, outcomes slightly exceeded guideline recommended benchmarks but may remain clinically acceptable; accordingly, its use should be restricted to selected cases, primarily as a bailout strategy or when standard revascularisation is not feasible in those at highest risk of neurological recurrence.