Predictors of postoperative stroke after transfemoral carotid artery stenting

In 2023, the Centers for Medicare and Medicaid Services expanded coverage for transfemoral carotid artery stenting (tfCAS) to include standard-risk patients. Given this shift, we sought to identify predictors of postoperative stroke in patients undergoing tfCAS.

We analyzed Vascular Quality Initiative data from 2011 to 2024, identifying tfCAS patients treated for atherosclerosis or restenosis. We excluded patients with interventions outside the internal carotid artery or bifurcation and procedures with concurrent intracranial treatment. We then stratified patients based on in-hospital postoperative stroke status. Baseline characteristics and outcomes were compared using χ² tests, and factors associated with stroke risk were compared using logistic regression. Ten-fold cross-validation was used to identify predictors of stroke, and a point system was developed to predict the risk of in-hospital postoperative stroke.

In our cohort of 35,346 tfCAS cases, 693 patients (2%) had an in-hospital post-procedure stroke. Patients who had a post-procedure stroke were older, more likely to be female, non-White, and had a higher overall comorbidity burden. After 10-fold cross-validation using the original logistic regression model, the factors most strongly associated with increased odds of stroke included uncontrolled hypertension (23% vs 14%; adjusted odds ratio [aOR], 2.66; 95% confidence interval [CI], 1.94-3.71; P < .001), emergent surgery (41% vs 32%; aOR, 2.39; 95% CI, 1.74-3.27; P < .001), severe distal tortuosity (13% vs 8%; aOR, 1.62; 95% CI, 1.25-2.27; P < .001), age greater than 75 years (41% vs 32%; aOR, 1.53; 95% CI, 1.23-1.92; P < .001), preoperative stroke (44% vs 29%; aOR, 1.57; 95% CI, 1.30-1.90; P < .001), prior carotid endarterectomy (14% vs 12%; aOR, 1.44; 95% CI, 1.14-1.81; P = .002), type III arch (7.1% vs 5.5%; aOR, 1.45; 95% CI, 1.02-2.03; P = .03), and circumferential or protruding calcification (3.3% vs 1.7%; aOR, 1.43; 95% CI, 1.04-1.93; P = .02). Dual antiplatelet therapy and having a high-volume physician or center were associated with lower odds of stroke. Based on variable importance, a simplified point system was developed to predict postoperative stroke (receiver operating characteristic area under the curve = 0.68).

The identified mediators of stroke risk after tfCAS offer the opportunity to improve patient selection. These data highlight the importance of managing modifiable factors preoperatively, such as hypertension and antiplatelet therapy. The timing of surgery also emerged as a strong predictor of stroke, suggesting the need for careful consideration of the need for emergent or urgent surgery. Anatomic considerations such as vessel tortuosity, arch type, and calcification should also prompt consideration for an alternate revascularization strategy.