Outcomes of Carotid Revascularization in Patients with Symptomatic Mildly Stenotic Carotid Disease
Ahmed Abdelkarim1, Mikayla Kricfalusi2, Ammar Abdullah1
1Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA.
Background:
Medical therapy alone is widely considered effective for symptomatic low-grade (≤50%) carotid artery stenosis (SxLGS). While mildly stenotic plaques generally carry a lower stroke risk than moderate-to-severe stenotic plaques, advanced imaging has identified high-risk features, such as intraplaque hemorrhage and ulceration, which are associated with an increased stroke risk and necessitate intervention if symptomatic. The evidence regarding symptomatic low-grade carotid stenosis management remains unclear. We aim to investigate patients with SxLGS in the VQI database by evaluating postoperative outcomes following carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS).
Methods:
This is a retrospective analysis of CEA, TCAR, and TFCAS done for SxLGS patients in the VQI database from 2016 to 2024. Atherosclerotic lesions were only included. The degree of stenosis was classified using duplex ultrasonography as follows: low-grade stenosis (LGS) (<50%), moderate-grade stenosis (MGS) (50-69%), and severe-grade stenosis (SGS) (70-99%). The primary outcomes were in-hospital and 1-year stroke and death, comparing the three procedures in each degree of stenosis cohort. Moreover, we conducted a subanalysis based on procedure type. Kaplan-Meier estimates, along with logistic and Cox regression models, were utilized for the analysis.
Results:
A total of 2,700 patients with SxLGS (66% CEA, 10% TFCAS, and 24% TCAR) were identified. Multivariate analysis revealed that in patients with LGS, TCAR was linked to a lower risk of in-hospital stroke compared to CEA (adjusted odds ratio [aOR] = 0.44 [95% confidence interval [CI]: 0.21- 0.93]; P = 0.03) and TFCAS (aOR = 0.28 [95% CI: 0.11- 0.69]; P = 0.006). However, there was no significant difference among the three procedures in those with MGS. In SGS, TFCAS was linked to a higher risk of in-hospital stroke/death compared to CEA (aOR = 1.4[95% CI: 1.03-1.85]; P = 0.03), while TCAR and CEA were comparable (aOR = 1.57[95% CI: 0.76- 3.27]; P = 0.2). After comparing the three grades of carotid stenosis, we found that LGS was associated with a higher odds of in-hospital stroke/death compared to SGS following CEA (aOR = 1.52 [95% CI: 1.09-2.08]; P = 0.014) and TFCAS (aOR = 2.13 [95% CI: 1.14-4]; P = 0.018) but not TCAR (aOR = 0.64 [95% CI: 0.31-1.28]; P = 0.208). At 1 year, TFCAS was associated with the lowest stroke-free survival among patients with LGS.
Conclusion:
In this multi-institutional study, we reviewed outcomes of carotid revascularization in SxLGS patients. TCAR emerged as a superior minimally invasive option, showing a lower rate of stroke/death compared to both CEA and TFCAS. Future studies are required to confirm those findings and refine SxLGS patient selection by including a medical therapy-only arm.
