Comparative analysis of stroke-related disability and mortality after carotid endarterectomy and carotid artery
Mohammed Hamouda1, Ahmed Abdelkarim1, Sina Zarrintan1
1Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
Insights
Transfemoral carotid artery stenting (TFCAS) is associated with more severe and lethal strokes compared to carotid endarterectomy (CEA) and transcarotid artery revascularization (TCAR). Outcomes up to one year also show higher risks for TFCAS patients.
Area of Science:
- Vascular Surgery
- Neurology
- Clinical Outcomes Research
Background:
- Carotid revascularization procedures (CEA, TCAR, TFCAS) aim to reduce stroke risk.
- Evidence comparing stroke severity across these procedures is limited.
Purpose of the Study:
- To quantify and compare the severity of postoperative strokes after CEA, TCAR, and TFCAS using the modified Rankin Scale (mRS).
- To evaluate functional outcomes and the debilitating/fatal consequences of strokes across different carotid revascularization methods.
Main Methods:
- Analysis of the Vascular Quality Initiative database (Sept 2016 - Aug 2024) for patients with postoperative stroke.
- Stroke severity quantified by mRS (0-6); severe stroke defined as mRS >4.
- Multivariable logistic and Cox regression models used to compare stroke severity, mortality, and recurrent stroke risks between TFCAS/TCAR and CEA.
Main Results:
- Among 2752 patients with postoperative stroke, TFCAS had the highest rate of severe strokes (30.7%) compared to CEA (21.2%) and TCAR (19.1%).
- Strokes after TFCAS were more likely to be severe (aOR 1.75) and lethal (aOR 1.79) compared to CEA.
- TFCAS also showed increased 1-year hazard for stroke/death (aHR 1.28) compared to CEA, while TCAR outcomes were similar to CEA.
Conclusions:
- Postoperative stroke severity differs significantly among carotid revascularization procedures.
- Transfemoral carotid artery stenting (TFCAS) is associated with more disabling and lethal strokes than CEA and TCAR.
- Carotid endarterectomy (CEA) and transcarotid artery revascularization (TCAR) demonstrate similar stroke magnitudes postoperatively and up to one year.
Objective:
Although previous studies have compared stroke risk after different carotid revascularization procedures, limited evidence exists on whether the magnitude of stroke is procedure-dependent. This study aims to quantify and compare the severity of strokes after carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) using the modified Rankin Scale (mRS). By evaluating functional outcomes, we provide insights into debilitating and fatal consequences of strokes across these procedures.
Methods:
The Vascular Quality Initiative database was queried from September 2016 to August 2024 for patients who suffered a postoperative stroke after their carotid revascularization procedure. The magnitude of the stroke was quantified using mRS 0 to 6 (0 = stroke with no symptoms; 6 = stroke leading to death). Patients who did not experience stroke after the index procedure were excluded. A severe stroke was defined as one having mRS >4. Multivariable logistic regression modelling was used to associate the likelihood of severe stroke occurrence after TFCAS and TCAR with reference to CEA. Multivariable Cox regression, Kaplan-Meier estimates, and the log-rank test analyzed the hazard of mortality as well as the risk of suffering a subsequent ipsilateral stroke within 1 year of the index stroke.
Results:
A total of 2752 patients who suffered a postoperative stroke after all three procedures were included in our analysis: CEA, 1476 (53.6%); TCAR, 748 (27.2%); and TFCAS, 528 (19.2%). Overall, 22.5% of the postoperative strokes had mRS >4. When stratifying by procedure type, TFCAS had the highest rate of severe strokes (CEA 21.2% vs TCAR 19.1% vs TFCAS 30.7%; P < .001). After adjusting for confounding variables, postoperative strokes after TCAR and CEA had similar magnitude (mRS >4: adjusted odds ratio [aOR], 0.85; 95% confidence interval [CI], 0.67-1.09; P = .200). However, strokes after TFCAS had higher likelihood of being severe (aOR, 1.75; 95% CI, 1.26-2.43; P = .001; aOR, 1.45; 95% CI, 1.05-2.00; P = .024) and lethal (mRS = 6: aOR, 1.79; 95% CI, 1.18-2.71; P = .006; aOR, 1.47; 95% CI, 1.03-2.10; P = .036) compared with CEA and TCAR, respectively, especially in symptomatic patients. Similarly, TFCAS had increased hazard of recurrent stroke, death, and stroke/death at 1 year (adjusted hazard ratio [aHR], 1.29; 95% CI, 1.03-1.61; P = .024; aHR, 1.39; 95% CI, 1.02-1.89; P = .039; and aHR, 1.28; 95% CI, 1.04-1.56; P = .018, repectively) compared with CEA, whereas no difference was seen in 1-year outcomes of TCAR vs CEA (P > .05). Furthermore, CEA demonstrated the highest unadjusted stroke-free survival among the three procedures.
Conclusions:
Based on this large multi-institutional study, we were able to show that not all postoperative strokes after carotid procedures are of the same magnitude. Using the mRS for stroke severity stratification, strokes after TFCAS were found to be the most disabling and lethal, whereas strokes after TCAR and CEA had similar magnitude postoperatively and up to 1 year of follow-up.
