Patients with patent foramen ovale or atrial septal defect after TCAR had significantly increased stroke risk, with odds ratios of 3.581 at 30 days and 5.809 all-time post-procedure.
Does the presence of PFO or ASD increase the risk of ischemic stroke in patients undergoing transcarotid artery revascularization (TCAR)?
The presence of PFO or ASD in patients undergoing transcarotid artery revascularization is associated with a substantially increased risk of ischemic stroke, particularly in the early post-procedural period.
Objective: Carotid artery disease, patent foramen ovale (PFO), and atrial septal defect (ASD) are known risk factors for development of acute ischemic stroke. Stroke occurrence in patients with ASD or PFO who have undergone transcarotid artery revascularization (TCAR) is not well studied. The purpose of this study is to investigate the risk of stroke in patients with known ASD or PFO after undergoing TCAR. Methods: Using de-identified electronic health records from the TriNetX Research Network, we created two cohorts: the first contained patients with a diagnosed patent foramen ovale (PFO) or atrial septal defect (ASD) with a history of transcarotid artery revascularization (TCAR) procedure (TCAR/ASD+/PFO+) between the ages of 1 and 90 years; the second group contained patients without a PFO or ASD with a history of TCAR procedure (TCAR/ASD-/PFO-) between the ages of 0 and 90 years. Analyses were conducted centered around these 2 cohorts (TCAR/PFO+/ASD+ and TCAR/PFO-/ASD-). Patients were 1:1 propensity matched by age, sex, and race. The risk of stroke was assessed at 30 days, 90 days, 1 year, and all-time after the index event. Analysis techniques including measures of association and survival were conducted across these different time points after TCAR. Results: A total of 54,546 patients were identified in this study. After 1:1 propensity score-matching, there were 2,134 patients (mean SD age, 63.8 17.9, 1,101 females 51.6%) in the TCAR/ASD+/PFO+ cohort and 2,134 patients (mean SD age, 64.4 17.1, 1,080 females 50.6%) in the TCAR/ASD-/PFO- cohort. A diagnosis of ASD/PFO is associated with a higher risk of ischemic stroke (p < 0.001) at 30 days, 90 days, 1 year, and all-time. The odds of developing a stroke were also significantly increased at all time points: 30 days (OR (CI), 3.581 (3.155, 4.064)), 90 days (OR (CI), 4.263 (3.742, 4.857)), 1 year (OR (CI), 5.086 (4.441, 5.824)), and all-time (OR (CI), 5.809 (5.036, 6.669)). Patients with ASD/PFO had a median survival of 5 days after TCAR before developing a stroke compared to 1317 days in those without ASD/PFO. Conclusion: This study demonstrates that individuals with PFO/ASD who underwent TCAR were at an increased risk of developing a stroke at 30 days, 90 days, 1 year, and all-time with the odds of developing a stroke increasing with time since intervention. Despite its relevance, currently there is limited literature available on this topic which warrants further investigation.
Evans et al. (2026) studied this question. Patients with patent foramen ovale or atrial septal defect after TCAR had significantly increased stroke risk, with odds ratios of 3.581 at 30 days and 5.809 all-time post-procedure.