Introduction/Purpose Current revascularization guidelines for symptomatic carotid artery stenosis were established based on randomized studies where stenosis was assessed with digital subtraction angiography (DSA). Pursuing revascularization in clinical practice is typically based on non‐invasive imaging. We aimed to assess whether discrepancies exist between these two diagnostic methods when patients with recently symptomatic carotid stenosis are referred for carotid revascularization based on non‐invasive imaging and subsequently undergoing DSA. Methods A retrospective study of patients presenting at three centers in the United States and Türkiye who routinely performed DSA prior to revascularization between 2019 and 2024 was conducted. Inclusion criteria included patients with acute cerebral ischemic events and concern for symptomatic ipsilateral carotid artery stenosis with moderate to severe stenosis on subsequent non‐invasive imaging referred for DSA. DSA was performed for intended carotid artery stenting in most cases as the first‐line treatment method; patients referred for carotid endarterectomy (CEA) who underwent pre‐procedure DSA were also included. Exclusion criteria included CEA or transcarotid artery revascularization (TCAR) without prior DSA or presence of intraluminal thrombus precluding immediate revascularization. The primary outcome was the rate of disagreement between non‐invasive imaging and DSA. Results 463 patients (65% males) were included, with a median age of 69 years. Disagreement regarding qualifying lesion severity for revascularization between non‐invasive imaging and DSA was found in 22.7% of patients. There was a significant difference in the proportion of immediate revascularization between the two cohorts (p<0.001). 66/105 (63%) of those in the disagreement cohort were determined to have an etiology of stroke alternative to large artery atherosclerosis, requiring further diagnostic evaluation. Conclusion This study demonstrates that almost 1 in 4 patients referred for carotid revascularization based on non‐invasive imaging are found to have insufficient stenosis on DSA to support the decision to proceed with revascularization according to established stenosis severity thresholds.
Iqbal et al. (Sat,) studied this question.