Carotid Artery Stenting Outcomes by Neurointerventional Surgeons (CASONI)

Multiple studies have highlighted the importance of carotid artery stenting (CAS) operator's experiences. However, fellowship-trained neurointerventionalists remain an under-represented specialty in the literature. We aim to report the complication rate of CAS performed exclusively by neurointerventionalists.

Retrospective cohort study regarding stenting symptomatic and asymptomatic carotid stenosis was collected at multiple comprehensive stroke centers. The primary outcome included a composite of the 30-day periprocedural mortality, symptomatic ischemic stroke, symptomatic intracranial hemorrhage, and myocardial infarction. The secondary outcomes included other complications. Chi-squared tests were performed for categorical variables, and Welch's t-test was used for continuous variables. Cutoffs in continuous variables were estimated using grid search optimization. Sensitivity analyses were performed for missing data.

Between 2018 and 2022, 1445 CAS procedures were performed by 38 neurointerventionalists. We have 30-day outcome data on 1281 patients. Patients were predominantly symptomatic (93.01%), male (65.79%), White (70.36%), and had a median age of 69. The primary outcomes occurred in 26 (1.8%) cases, with 13 (0.9%) death, 8 (0.55%) symptomatic ischemic stroke, 4 (0.28%) symptomatic intracranial hemorrhage, and 1 (0.07%) myocardial infarction. A statistically significant increase in all outcomes correlated with advanced age (P = 0.001), women (P = 0.013), aortic arch type 3 (P = 0.01), and higher preprocedural modified Rankin score (P = 0.006). Secondary outcomes were higher in Hispanic and Black patients (P = 0.007) and those with low diastolic blood pressure at stenting (P = 0.04).

CAS, conducted by fellowship-trained neurointerventionalist physicians in comprehensive stroke centers, demonstrates a lower complication rate than what was previously reported in CAS, carotid endarterectomy, and transcarotid artery revascularization literature. Physician training, higher frequency, and standardized stroke care in a comprehensive stroke center may contribute to this low complication rate.