Urgent/emergent carotid revascularization is associated with an increase in stroke and mortality

Despite few clinical indications, numerous urgent or emergent carotid procedures have been recorded in the Vascular Quality Initiative (VQI) database. As such, we sought to assess outcomes of urgent and emergent carotid revascularization in the VQI.

We identified all patients who underwent carotid revascularization in the VQI from 2011 to 2024. Patients were stratified by urgency status, preoperative symptom status, and procedure type. Elective revascularization was defined by the VQI as a planned or scheduled procedure, urgent as surgery within 24 hours, and emergent as surgery within 6 hours. We excluded patients whose primary procedure was a planned intracranial treatment, as well as patients presenting with trauma, dissection, or other nonatherosclerotic indications. The primary outcome was perioperative stroke or death. Secondary outcomes included perioperative death and stroke. We used χ² and logistic regression to evaluate perioperative outcomes.

Of the 317,163 carotid revascularizations performed, 268,091 (84%) were elective, 45,021 (14%) were urgent, and 4051 (1%) were emergent. Most urgent (29,958, 67%) or emergent (2,956, 73%) cases were symptomatic, although there were 15,063 urgent (34%) and 1095 emergent (27%) among asymptomatic patients. Stroke was the indication for 44% of urgent procedures and 62% of emergent procedures. There 45,021 cases classified as urgent, of which 28,063 (62%) were carotid endarterectomy, 8172 (18%) transcarotid artery revascularization, and 8786 (19.5%) transfemoral carotid artery stenting. Of the 4051 emergent procedures, 1235 (31%) were carotid endarterectomy, 182 (4.5%) transcarotid artery revascularization, and 2634 (65%) transfemoral carotid artery stenting. Compared with elective procedures, among all patients, urgent procedures were associated with increased odds of stroke/death (3.2% vs 1.2%; adjusted odds ratio [aOR], 1.99; 95% confidence interval [CI], 1.80-2.18; P < .01), as were emergent procedures (10.4% vs 1.2%; aOR, 3.67; 95% CI, 3.03-4.44; P < .01). These differences were also noted following subset analyses of asymptomatic (urgent, 3.0% vs 1.0%; aOR, 2.52; 95% CI, 2.16-2.92; P < .01) and (emergent, 9.9% vs 1.0%; aOR, 5.5; 95% CI, 3.91-7.63; P < .01) and symptomatic patients (urgent, 3.3% vs 1.7%; aOR, 1.65; 95% CI, 1.46-1.86; P < .01) and (emergent, 11% vs 1.7%; aOR, 3.07; 95% CI, 2.43-3.86; P < .01). These differences persisted after stratifying by procedure type, for both asymptomatic and symptomatic patients.

Urgent or emergent carotid revascularization was associated with higher odds of perioperative stroke or death, stroke, and death. Given the increased risks of urgent or emergent surgery, careful consideration should be given when assessing patients who may ostensibly benefit from expedited surgery, where possible.