Effect of Perioperative Stroke on Survival After Carotid Intervention
Tommaso Cambiaghi1, Alexander Mills1, Samuel Leonard1
1Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA.
Insights
Perioperative stroke during carotid interventions significantly impacts early survival. Transcarotid artery revascularization (TCAR) patients experienced lower survival, potentially due to higher baseline risk factors.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurosurgery
Background:
- Perioperative stroke is a major complication of carotid artery interventions.
- Carotid interventions aim to reduce stroke risk in patients with carotid stenosis.
- Evaluating the impact of perioperative stroke on mortality across different intervention modalities is crucial.
Purpose of the Study:
- To assess the impact of perioperative stroke on mortality in patients undergoing carotid revascularization.
- To compare the outcomes of carotid endarterectomy (CEA), transfemoral carotid stenting (TF-CAS), and transcarotid artery revascularization (TCAR).
- To analyze the effect of stroke on survival rates across different treatment modalities.
Main Methods:
- Retrospective analysis of patients undergoing carotid revascularization from 2003-2022.
- Stratification of patients based on treatment modality: CEA, TF-CAS, and TCAR.
- Analysis of perioperative outcomes (stroke, mortality) and follow-up survival data.
Main Results:
- Overall stroke incidence was 2.1%, with no significant difference between CEA (2.1%), TCAR (1.7%), and TF-CAS (3.6%).
- Perioperative death rate was 2.1%, significantly higher in patients with intraoperative stroke (8.3% vs 1.9%).
- Transcarotid artery revascularization (TCAR) patients had lower 6-month and 12-month survival compared to CEA and TF-CAS.
Conclusions:
- Perioperative stroke significantly impacts early survival after carotid interventions.
- The increased mortality associated with stroke appears more pronounced in TCAR patients, likely due to their higher-risk profile.
- Mid-term outcomes at 5 years showed no apparent change, highlighting the acute impact of perioperative stroke.
Objectives:
Perioperative stroke is the most dreaded complication of carotid artery interventions and can severely affect patients' quality of life. This study evaluated the impact of this event on mortality for patients undergoing interventional treatment of carotid artery stenosis with three different modalities.
Methods:
Patients undergoing carotid revascularization at participating Memorial Hermann Health System facilities were captured from 2003-2022. These patients were treated with either carotid endarterectomy (CEA), transfemoral carotid stenting (TF-CAS), or transcarotid artery revascularization (TCAR). Perioperative outcomes, including stroke and mortality, as well as follow-up survival data at 6-month intervals, were analyzed and stratified per treatment modality.
Results:
Of the 1681 carotid revascularization patients identified, 992 underwent CEA (59.0%), 524 underwent TCAR (31.2%), and 165 underwent TF-CAS (9.8%). The incidence of stroke was 2.1% (CEA 2.1%, TCAR 1.7%, and TF-CAS 3.6%; P = .326). The perioperative (30-day) death rate was 2.1% (n = 36). The perioperative death rate was higher in patients who suffered from an intraoperative stroke than in those who did not (8.3% vs 1.9%, P = .007). Perioperative death was also different between CEA, TCAR, and TF-CAS for patients who had an intraoperative stroke (.0% vs 33.3% vs .0%, P = .05). TCAR patients were likely to be older (P < .001), have a higher body mass index (P < .001), and have diabetes mellitus (P < .001). Patients who suffered from an intraoperative stroke were more likely to have a symptomatic carotid lesion (58.3% vs 28.8%, P < .001). The TCAR group had a significantly lower survival at 6 months and 12 months when compared to the other two groups (64.9% vs 100% P = .007).
Conclusion:
Perioperative stroke during carotid interventions significantly impacts early patient survival with otherwise no apparent change in mid-term outcomes at 5 years. This difference appears to be even more significant in patients undergoing TCAR, possibly due to their baseline higher-risk profile and lower functional reserve.
