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Assessing the Impact of Distal ICA Tortuosity on Outcomes in Carotid Revascularization: A Comparative Analysis of Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting
Sabrina L Straus
1, Carine Tamamian
1, Sina Zarrintan
1, Ahmed Abdelkarim
1, Jeffrey Siracuse
2, Mahmoud Malas
1 1UCSD, La Jolla, CA;
2Boston Medical Center, Boston, MA
Objective: Distal 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 impact of distal ICA tortuosity on the outcomes of Transcarotid Artery Revascularization (TCAR) compared to traditional transfemoral carotid artery stenting (TFCAS).
Methods: A retrospective analysis was conducted on patients undergoing TCAR or TFCAS for carotid stenosis from 2016 onward, utilizing the Vascular Quality Initiative. ICA tortuosity was categorized as none/mild (no S-curve or minor S-curve with bends ≤ 75 degrees), moderate (S-curve with 2 bends > 75 degrees or 1 bend > 90 degrees), or severe (S-curve with 2 bends > 90 degrees or the presence of redundant loops and coils). The primary outcome was in-hospital stroke or death; secondary outcomes included postoperative myocardial infarction (MI), extended hospital stay, and 1-year mortality. Inverse probability weighting was employed to balance groups and evaluate outcomes.
Results: 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 (CAD). In the overall population, severe tortuosity patients had the highest rates of adverse events compared to those with moderate or none/mild tortuosity (Table I). 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% vs. 3.7%, aOR 2.42, 95% CI 1.45-4.02, p < 0.001) or severe (1.7% vs. 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% vs. 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 (Table II).
Conclusion: Distal ICA tortuosity significantly influences outcomes in carotid revascularization, with severe tortuosity correlating with increased perioperative complications, particularly in TFCAS. TCAR outperformed TFCAS in patients with moderate to severe tortuosity, suggesting it as the preferred approach in this patient population, as it eliminates the need for distal filter placement while allowing for the use of flow reversal. This study highlights the importance of tailoring carotid revascularization strategies to individual anatomic considerations to optimize patient outcomes.
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