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INTRODUCTION:
The Center for Medicare and Medicaid Services (CMS) considers that contralateral carotid artery occlusion puts the patient at high risk for endarterectomy (CEA) and agrees to reimburse for carotid artery stenting (CAS) in those patients. However, there is paucity of evidence that support the superiority or the equipoise of CAS compared to CEA in patients with contralateral carotid occlusion.
METHODS:
All patients who underwent CEA or CAS with contralateral occlusion were identified in the Vascular Quality Initiative registry between 2005 and 2016. Outcomes examined were stroke, death and MI at 30 days and stroke and death at 2 years stratified by ipsilateral symptomatic status. Multivariable logistic regression analysis was implemented to estimate the odds ratios of 30-day outcomes controlling for patient’s demographic characteristics, degree of stenosis, comorbidities and medications. Life tables, robust Cox proportional hazard clustered by centers, and log rank tests were implemented to estimate the hazard ratios for long-term events.
RESULTS:
Overall, 4,326 patients had contralateral occlusion [CEA: 3,274 (75.7%) versus CAS: 1,052 (24.3%)]. In general, patients’ demographic and comorbidities were similar in both groups, except for race in which black patients were more likely to have CAS (9.5% vs. 7.6%; P=.048), history of previous stroke was more prevalent in patients undergoing CEA (56.4% vs. 24.0%; P<.001) and history of congestive heart failure was more common in CAS patients (15.6% vs. 9.6%; P<.001). CAS patients were more likely to present with ipsilateral symptoms (41.2% vs. 24.2%; P.05), (Table). Similarly, the 2-year risk of ipsilateral stroke didn’t differ significantly between CAS and CEA patients, however, the risk of any stroke or death was 49% higher with CAS [adjusted hazard ratio (95%CI): 1.40 (1.06-1.85); P=.02] (Figure). In symptomatic patients, CAS was associated with almost three folds higher risk for 30-day stroke and over four folds the 30-day mortality [OR (95%CI): 2.77 (1.07-7.21), P=.036] and [OR (95%CI): 4.61(1.63-13.03), P=.004] respectively (Table). Two-year stroke was similar but the risk of any stroke or death was 82% higher with CAS [aHR (95%CI): 1.85 (1.11-3.06); P=0.02]. (Figure)
CONCLUSIONS:
In this exclusive large cohort of patients with contralateral carotid artery occlusion, CAS performance was not better compared to CEA in asymptomatic patients in the perioperative period. However, symptomatic patients suffered significantly worse outcomes if they underwent CAS. Two-year stroke was not different between the two procedures but the risk of stroke or death was consistently higher for CAS patients. CAS is not safer than CEA in patients with contralateral occlusion and refinement of current guidelines is warranted to provide surgical care specifically tailored for patient’s presentation.

Table: Multivariable analysis of adverse outcomes comparing CAS to CEA.

Outcomes	Asymptomatic Patients		Symptomatic Patients
	Adjusted Risk estimate* (95%CI)	P value	Adjusted Risk estimate (95% CI)	P value
30-day stroke	0.92 (0.42-2.02)	.842	2.77 (1.07-7.21)	.036
30-day mortality	1.60 (0.74-3.45)	.229	4.61 (1.63-13.03)	.004
30-day MI	1.29 (0.57-2.93)	.542	0.14 (0.02-1.10)	.062
30-days MACE	1.24 (0.75-2.04)	.401	2.09 (1.06-4.11)	.034
Two-year ipsilateral stroke	1.43 (0.63-3.24)	.393	1.67 (0.67-4.13)	.270
Two-year stroke/death	1.40 (1.06-1.85)	.020	1.85 (1.11-3.06)	.020
*Risk estimate is odds ration in 30-day outcomes and hazard ratios in two-year outcomes