Association of Distal Internal Carotid Artery Tortuosity With Carotid Artery Stenting Outcomes

Distal cervical internal carotid artery (ICA) tortuosity has been associated with challenges in carotid revascularization, influencing procedural choice and outcomes. Understanding how this anatomy affects the success of different revascularization techniques is critical for optimizing patient care. The aim of this study was to evaluate the association of distal ICA tortuosity on the outcomes of transcarotid artery revascularization (TCAR) compared to traditional transfemoral carotid artery stenting (TFCAS).

A retrospective analysis was conducted on all patients undergoing TCAR or TFCAS for carotid stenosis from September 2016 to March 2024, utilizing the Vascular Quality Initiative. ICA tortuosity was categorized as none/mild (no S-curve or minor S-curve with bends ≤75°), moderate (S-curve with 2 bends >75° or 1 bend >90°), or severe (S-curve with 2 bends >90° or the presence of redundant loops and coils). The primary outcome was in-hospital stroke or death; secondary outcomes included postoperative stroke, death, myocardial infarction (MI), extended hospital stay, and 1-year mortality. Inverse probability weighting was employed to balance groups, adjust for confounders, and evaluate outcomes.

Among 70,163 CAS patients included in this study, patients with severe ICA tortuosity tended to have more comorbidities, including a higher prevalence of obesity, diabetes, and coronary artery disease. In the overall population, severe tortuosity patients had the highest rates of adverse events compared to those with moderate or none/mild tortuosity. When comparing TFCAS with TCAR based on tortuosity status, patients who underwent TCAR had lower in-hospital death and 1-year mortality rates, regardless of tortuosity status. However, only patients with moderate (1.5% versus 3.7%, adjusted odds ratio (aOR): 2.42, 95% confidence interval (CI): 1.45-4.02, P < 0.001) or severe (1.7% versus 5.0%, aOR: 3.15, 95% CI: 1.54-6.43, P = 0.002) tortuosity had significantly lower stroke rates with TCAR compared with TFCAS while none/mild tortuosity patients had no significant differences. In contrast, severe ICA tortuosity was associated with higher odds of MI in TCAR versus TFCAS (1.2% versus 0.2%, aOR: 0.19, 95% CI: 0.07-0.56, P = 0.003). There were no significant differences in MI between TFCAS and TCAR in patients with none/mild or moderate tortuosity.

Distal ICA tortuosity plays an important role in carotid revascularization procedural selection, with severe tortuosity correlating with increased perioperative complications, particularly in TFCAS. In patients with moderate to severe tortuosity, TCAR was associated with lower rates of adverse outcomes compared with TFCAS. This study highlights the importance of tailoring carotid revascularization strategies to individual anatomic considerations to optimize patient outcomes.