Outcomes of Carotid Artery Stenting for Dissection Are Prohibitive
Isibor J. Arhuidese1, Charles J. Bailey1, Isaac Naazie2, Mahmoud B. Malas2, Mary E. Ottinger1, Murray L. Shames1
1University of South Florida, Tampa, FL, 2University of California San Diego, San Diego, CA
Background: The treatment of flow limiting lesions in the carotid artery for the prevention of stroke has evolved over time. Alternative approach to the trans-femoral route to carotid stenting has gained relevance in recent times. It is speculated that trans femoral carotid artery stenting (TFCAS) will become obsolete. However, it is likely to remain useful in unique circumstances and should remain part of the armamentarium of the modern vascular surgeon. One domain in which TFCAS will remain relevant is in the treatment of carotid dissection. The trans-femoral route is favored in this setting given the need to reliably identify the true lumen. This is aided by accessing the origin of the carotid artery and preceding length of non-dissected vessel.Most flow limiting carotid lesions are atherosclerotic in etiology. The vast majority of studies that have evaluated the safety of the various modes of carotid intervention have excluded patients with dissections. Accordingly, there is limited data on the outcomes of TFCAS for the treatment of carotid dissection. Prior studies are limited to case reports and series with samples of less than 10 patients. The Society for Vascular Surgery guidelines for the management of carotid dissection acknowledges insufficient data to support the role of carotid stenting in this domain and recommend stenting for patients who remain symptomatic on medical therapy. This is in alignment with recommendations from the European Society for Vascular Surgery and others. In clinical practice, the presence of a dissection flap in the carotid artery can be anxiety laden, thus leaving some practitioners eager to stent the lesion. However, such enthusiasm must be tempered with objective assessment of risk relative to perceived benefit. This is especially important given the benign progression of asymptomatic carotid dissections that has been described in natural history studies. For these reasons, the objective of this study was to evaluate
the outcomes of trans-femoral carotid stenting for the treatment of carotid dissection from a contemporary large representative cohort of patients.
Methods: We performed a retrospective analyses of the cohort of all patients in the Vascular Quality Initiative (VQI) who underwent trans-femoral carotid artery stenting for dissection between January-2006 and December-2019. The VQI is a prospective database maintained by the Society for Vascular Surgery for patient safety and quality improvement. The indication for carotid stenting “dissection” was identified directly from the VQI database. Patients with trauma and fibromuscular dysplasia were excluded. Symptomatic status was determined by the reporting physician. The successful use or nonuse of an embolic protection device (EPD) was identified in the database. The outcomes of interest were new ipsilateral peri-procedural stroke, myocardial infarction (MI), 30-day mortality as well as the composites of 30-day stroke/death and 30-day stroke/death/MI and length of stay. Peri-procedural ipsilateral stroke was defined as new cortical, vertebro-basilar or ocular stroke within 30-days of the procedure. Myocardial infarction was a clinical or EKG confirmed diagnosis or a critical elevation in troponins. The composite end points of 30-day stroke/death; and 30-day stroke/death/MI were included in accordance with reference clinical trials. Baseline patient characteristics and absolute outcomes were evaluated using chi-square, and t-tests as appropriate. Risk adjusted analyses were performed using multivariable logistic regression adjusting for clinically relevant variables.
Results: There were 608 patients who underwent trans-femoral carotid stenting for carotid dissection. Median follow-up duration was of 337 days. The median age was 53 years (inter-
quartile range (IQR): 42-66 years). The prevalence of female gender and white race were 47% and 84% respectively (table 1). The majority of these procedures were performed in patients who were asymptomatic 416 (68.4%). EPD was used in 255 (41.9%) patients. The incidence of new peri-procedural ipsilateral stroke was 23.2%. This outcome was 32.9% for asymptomatic patients and 2.1% for symptomatic patients (p<0.001). The risk adjusted analyses showed no significant association between EPD use and new ipsilateral stroke (aOR: 0.78; 95%CI: 0.47-1.30; p=0.34) as this outcome remained high in patients with (20%) and without (25.5%) EPD use (p=0.11). Peri-procedural MI was 0.5% and 30-day mortality was 4.4%. The composite of 30-day stroke/death was 25.5% while 30-day stroke/death/MI was 26%. The increase in the composite outcomes were largely driven by the elevated peri-procedural stroke (table 2). There were no significant predictors of ipsilateral peri-procedural stroke identified. The median length of hospital stay was 4 days (IQR: 2-8 days).
Conclusions: The majority of carotid stents for dissection in this relatively large contemporary cohort were placed in asymptomatic patients. Trans femoral carotid artery stenting for carotid dissection is associated with prohibitive risk of peri procedural stroke in these patients. The use of embolic protection devices does not mitigate this high risk. The underpinnings of the disparate incidence of stroke between asymptomatic and symptomatic patients deserve further granular evaluation. None the less, the prevalent practice of carotid stenting of asymptomatic carotid dissections should be avoided.
Table 1: Characteristics of patients who underwent trans-femoral carotid stenting for dissection: all patients and within strata of symptoms and embolic protection device use.
| Patient characteristics | All patients | Symptoms | Embolic Protection Device (EPD) | ||||
| Asymptomatic416 (68.4%) | Symptomatic192 (31.6%) | P-value | EPD not used 353 (58%) | EPD used 255 (42%) | P-value | ||
| sAge in years, median (IQR) | 53 (42-66) | 53 (43-65) | 54 (40-68) | 0.53 | 50 (41-61) | 58 (44-71) | <0.001 |
| Female gender (%) | 46.9 | 47.6 | 45.3 | 0.6 | 43.9 | 51.0 | 0.085 |
| Race (%) | |||||||
| White | 84.2 | 85.8 | 80.7 | 0.001 | 84.1 | 84.3 | 0.85 |
| Black | 9.2 | 10.1 | 7.3 | 9.6 | 8.6 | ||
| Others | 6.6 | 4.1 | 11.9 | 6.2 | 7.1 | ||
| Symptoms (%) | - | - | - | - | 30.3 | 33.2 | 0.43 |
| Hypertension (%) | 53.8 | 51.9 | 57.8 | 0.18 | 46.7 | 63.5 | <0.001 |
| Diabetes mellitus (%) | 16.1 | 15.9 | 16.7 | 0.80 | 14.1 | 18.8 | 0.12 |
| Active smoking (%) | 26.8 | 27.4 | 25.5 | 0.64 | 27.6 | 25.7 | 0.61 |
| History of CAD (%) | 10.2 | 8.9 | 13.0 | 0.12 | 7.1 | 14.5 | 0.003 |
| History of CHF (%) | 4.9 | 4.3 | 6.3 | 0.31 | 4.3 | 5.9 | 0.36 |
| History of COPD (%) | 9.5 | 10.8 | 6.8 | 0.11 | 8.5 | 11.0 | 0.30 |
Table 2: Outcomes of trans-femoral carotid stenting in patients with carotid artery dissection within strata of symptoms and embolic protection device use
| Peri-procedural Outcome | Symptoms | Embolic Protection Device (EPD) | ||||
| Asymptomatic | Symptomatic | P-value | EPD not used | EPD used | P-value | |
| New ipsilateral stroke | 32.9 | 2.1 | <0.001 | 25.5 | 20 | 0.11 |
| MI | 0 | 1.6 | 0.011 | 0.3 | 0.8 | 0.38 |
| Death | 4.6 | 4.2 | 0.82 | 6.0 | 2.4 | 0.034 |
| 30-day stroke/death | 34.9 | 5.2 | <0.001 | 28.3 | 21.6 | 0.059 |
| 30-day stroke/death/MI | 34.9 | 6.8 | <0.001 | 28.6 | 22.4 | 0.082 |
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