The Impact of Concomitant Proximal Carotid Interventions on Revascularization and Outcomes
Chung-Fu Lin1, Sneha Thandra2, John Hallsten3
1Georgetown University School of Medicine, Washington, DC.
Background:
Tandem atherosclerotic stenosis involving the carotid bifurcation and ipsilateral proximal common carotid artery is uncommon and optimal management remains unclear. We evaluated perioperative outcomes following ipsilateral proximal endovascular intervention (IPE) combined with carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR).
Methods:
Patients undergoing concomitant proximal carotid intervention in the Vascular Quality Initiative registry between 2016 and 2023 were identified. Patients were stratified by procedure: IPE + CEA, IPE + TFCAS, and IPE + TCAR. The primary outcome was in-hospital stroke. Secondary outcomes included major adverse cardiac events (MACEs) and extended length of stay (LOS >1 day). Multivariable logistic regression was performed.
Results:
Our study included 843 (61.6%) IPE + CEA, 297 (21.7%) IPE + TFCAS, and 228 (16.7%) IPE + TCAR. TCAR patients were more likely to have history of stroke, greater than 80% ipsilateral carotid stenosis, diabetes, coronary artery disease, and chronic kidney disease compared to IPE + CEA and IPE + TFCAS. When compared to IPE + CEA, both IPE + TCAR and IPE + TFCAS exhibited no difference in stroke (adjusted odds ratio [aOR] = 1.07, P = 0.9), (aOR = 1.36, P = 0.473) and stroke/death/myocardial infarction (aOR = 0.4, P = 0.08), (aOR = 1.08, P = 0.81) but with a significant decrease LOS>1 (aOR = 0.59, P = 0.002), (aOR = 0.42, P < 0.001), respectively. Furthermore, IPE + TCAR and IPE + TFCAS had similar risk of stroke (aOR = 0.85, P = 0.764) and LOS>1 (aOR = 1.4, P = 0.12).
Conclusion:
There is no significant difference observed in the risk of stroke and MACEs in IPE + CEA, IPE + TFCAS, and IPE + TCAR. MACEs occurred less frequently, although not statistically significant, in the IPE + TCAR group and warrants additional investigation. Lastly, endovascular techniques were associated with shorter hospital stay. Further research is needed to establish a standard approach to this multilevel condition.