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Cerebral Hyperperfusion Syndrome Risk Comparison between Transcarotid Artery Revascularization and Carotid Artery
Christopher Y Chow1, Naixin Kang1, Stefan Kenel-Pierre1
1Vascular and Endovascular Surgery, University of Miami School of Medicine, Miami, FL.
Insights
Transcarotid artery revascularization (TCAR) significantly reduces cerebral hyperperfusion syndrome (CHS) risk and severity compared to carotid artery stenting with distal embolic protection (CAS+DEP) in symptomatic patients. TCAR also lowers mortality and hospitalization for CHS patients.
Area of Science:
- Vascular Surgery
- Neurology
- Interventional Cardiology
Background:
- Cerebral hyperperfusion syndrome (CHS) is a serious complication post-carotid revascularization.
- The impact of different carotid artery stenting (CAS) modalities on CHS is not well-defined.
Purpose of the Study:
- To compare the incidence, severity, and outcomes of CHS between transcarotid artery revascularization (TCAR) and CAS with distal embolic protection (CAS+DEP).
Main Methods:
- Retrospective analysis of 69,480 patients from the Vascular Quality Initiative (2016-2023).
- Patients underwent TCAR or CAS+DEP, stratified by symptom status and urgency.
- Primary outcome: CHS occurrence. Secondary outcomes: CHS severity, mortality, and hospitalization length.
Main Results:
- TCAR cohort had lower CHS incidence (0.53% vs. 1.1%, P<0.001).
- TCAR showed a 2-fold lower CHS risk in symptomatic patients (aOR: 0.52, P<0.001).
- TCAR patients with CHS experienced reduced mortality, shorter hospitalization, and less severe CHS.
Conclusions:
- TCAR is associated with a lower risk of CHS than CAS+DEP in symptomatic patients.
- TCAR leads to milder CHS forms and better outcomes, including lower mortality, compared to CAS+DEP.
Background:
Cerebral hyperperfusion syndrome (CHS) is a rare but serious complication after carotid artery revascularization. This study aims to determine the impact of carotid artery stenting (CAS) modality on the incidence, severity, and overall outcomes of CHS after carotid revascularization.
Methods:
Data from patients who underwent CAS with either distal embolic protection (CAS + DEP) or transcarotid artery revascularization (TCAR) were obtained from the Vascular Quality Initiative database through the years 2016-2023. Cases without embolic protection device and patients suffering from carotid dissection, trauma, or fibromuscular dysplasia were excluded from the study. Patients were stratified into asymptomatic and symptomatic carotid stenosis groups and then further reviewed based on the urgency of their revascularization. The primary outcome was the occurrence of CHS after revascularization. A subgroup analysis was then performed, evaluating postprocedural outcomes and severity of CHS. Lastly, patients with CHS were further analyzed according to the severity of their stroke on admission using the Modified Rankin Scale.
Results:
In this analysis, a total of 69,480 (57.47% TCAR; 42.53% CAS + DEP) patients were included. Postprocedural CHS was lower in the TCAR cohort compared to the CAS + DEP cohort (0.53% vs. 1.1%, P < 0.001). On multivariate analysis, TCAR was associated with lower risk of CHS than CAS + DEP (P < 0.001). When considering only asymptomatic patients, revascularization modality did not significantly affect CHS occurrence (P = 0.610). However, in symptomatic patients, TCAR was associated with 2-fold lower risk of CHS (adjusted odds ratio (aOR): 0.52, 95% confidence interval (CI): 0.40-0.68, P < 0.001), in both elective (P = 0.003), and urgent/emergency cases (P < 0.001). Among patients who developed CHS, those undergoing TCAR had decreased in-hospital mortality (aOR: 0.51, 95% CI: 0.27-0.94, P = 0.031) and at 30 days (aOR: 0.46, 95% CI: 0.26-0.80, P = 0.006). TCAR patients with CHS also had a shorter length of hospitalization (aOR: 0.58, 95% CI: 0.36-0.92, P = 0.022) and suffered less frequently from severe CHS with seizures and intracranial hemorrhage (aOR: 0.51, 95% CI: 0.29-0.89, P = 0.019). Patients undergoing CAS + DEP who were admitted with severe stroke (Modified Rankin Scale 3-5) developed severe CHS (P = 0.014).
Conclusion:
In patients with symptomatic carotid artery stenosis, TCAR is associated with a lower risk of CHS compared to CAS + DEP. Among those who develop CHS, patients who undergo TCAR express a milder form of CHS and have lower in-hospital and 30-day mortality than those treated with CAS + DEP.
