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Addition of Common Carotid Intervention Increases the Risk of Stroke and Death after Carotid Artery Stenting for Asymptomatic Patients
Charles DeCarlo1, Adam Tanious1, Laura T. Boitano1, Jahan Mohebali1, David H. Stone2, W. Darrin Clouse3, Mark F. Conrad1
1Massachusetts General Hospital, Boston, MA, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH, 3University of Virginia, Charlottesville, VA

Background: A recent review of VSGNE data suggested that simultaneous endovascular treatment of tandem carotid lesions (common carotid artery (CCA)+internal carotid artery (ICA)) is associated with a four-fold increase in perioperative neurological events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous CCA and ICA stenting in cohorts stratified by symptom status.
Methods: VQI data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis<50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative neurologic events and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with tandem lesions forced into the models.
Results: There were 18,886 carotid arteries stented (18,441 patients); 18,077 (96%) with isolated lesions, 809 (4%) with tandem lesions. Mean age was 70.09.7. Symptomatic lesions were present in 58.9% of cases (isolated: 59.1% vs tandem: 52.5%; p<0.001). More tandem group arteries had a prior CEA (38.3% vs. 23.8%; p<0.001). Neuroprotection was more likely to be successfully deployed with isolated lesions (94.7% vs 91.1%; p<0.001). Tandem lesions had a higher perioperative stroke/death (4.7% vs 2.5%; p=0.007) for asymptomatic lesions, but not symptomatic lesions (5.4% vs 5.3%; p=0.92). Tandem lesions were independently associated with stroke/death in asymptomatic patients (OR 1.91;95%CI:1.16-3.16; p=0.012) but not symptomatic patients (Table).
Conclusion: Addition of endovascular treatment of tandem CCA lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of tandem lesions is not associated with an increased risk of stroke/death for symptomatic lesions.

Table: Multivariable Models for Stroke/Death for Asymptomatic and Symptomatic Lesions
Asymptomatic Lesions
Odds Ratio95% Confidence IntervalP-Value
Tandem Lesions1.911.163.160.012
Age (per year)1.051.031.07<0.001
Intraoperative Contrast (per 10 cc''s)1.021.001.040.016
CHF1.531.092.140.013
Preoperative P2Y12 Inhibitor0.520.380.71<0.001
Preoperative Statin0.640.460.900.011
Technical Failure2.491.016.130.048
Multiple Stents to Treat ICA Lesion2.321.373.930.002
Symptomatic Lesions
Odds Ratio95% Confidence IntervalP-Value
Tandem Lesions1.030.671.580.908
Age (per year)1.041.031.06<0.001
Intraoperative Contrast (per 10 cc''s)1.041.021.05<0.001
Symptomatic CHF1.411.071.850.013
Diabetes1.361.151.61<0.001
Preoperative ESRD on HD2.431.493.96<0.001
Preoperative P2Y12 Inhibitor0.790.660.960.018
Neuroprotection Success0.680.500.930.014

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