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Carotid Lesion Length Independently Predicts Stroke and Death After TransCarotid Artery Revascularization and TransFemoral Carotid Artery Stenting
Nadin Elsayed1, Maryam Ali Khan1, Munir Paul Moacdieh1, Ann Gaffey1, Jeffrey Siracuse2, Mahmoud Malas1
1University of California San Diego, San Diego, CA;2Boston Medical Center, Boston, MA

INTRODUCTION: Prior data from CREST suggested that the higher perioperative stroke or death event rate among patients treated with transfemoral carotid artery stenting (TFCAS) appears to be strongly related to the lesion length. Nonetheless, data regarding the impact of lesion length on outcomes of transcarotid artery revascularization (TCAR) with flow reversal is lacking. Herein, we aimed to compare the outcomes of TCAR versus TFCAS stratified by the length of carotid lesion.
METHODS: Our cohort was derived from the Vascular Quality Initiative (VQI) database for carotid artery stenting between 2016 and 2021. Restricted cubic spline analysis was used to describe the relationship between the primary outcome (in-hospital stroke/death) and the exposure variable (lesion length) in the overall cohort. This relationship was not linear, and the knots were identified where significant changes in the slope of the curve occurred. We therefore divided patients based on knot with the most significant inflection, into two groups: lesion length<25mm(short) and lesion length ≥25mm. Clinically relevant and statistically significantly variables on univariable analysis were added to the final logistic regression model clustered by center identifier to study the association between lesion length and in-hospital outcomes stratified by stent approach.
RESULTS: Results: A total of 17,106 patients were studied. A flow reversal time of 10 mins was identified as the critical cutoff predictive of neurological events. Flow reversal was applied for a duration of more than 10 mins in 47.7% of patients (n=8156). Patients in which flow reversal time was longer that 10 mins were less likely to have contralateral occlusion (7.0% vs 8.4%, P=0.001) but more likely to be obese (34.5% vs 32.6%, P=0.009), have COPD (26.7% vs 24.6%; P=0.002), be on preoperative aspirin (90.5% vs 89.5%; P=0.040) and statins (90.4% vs 89.2%; P=0.007), and to undergo TCAR under general anesthesia (84.0% vs 82.2%; P=0.002). Flow reversal beyond 10 mins was not significantly associated with outcomes among asymptomatic patients. Among symptomatic patients however, flow reversal time ? 10 mins was associated with 2-fold increased odds of intraoperative neurological intolerance (1.0% vs 0.5%; aOR, 2.18; 95%CI, 1.11-4.27; P=0.023), 2-fold increased odds of in-hospital stroke (2.8% vs 1.5%; aOR, 1.98; 95%CI, 1.35-2.92; P=0.001) and 92% increased odds in-hospital stroke/death (3.2% vs 1.7%; aOR, 1.92; 95%CI, 1.34-2.74; P<0.001), Table 1
CONCLUSIONS: In this large contemporary retrospective national study, carotid lesion length appears to negatively impact in-hospital outcomes for TCAR and TFCAS. In the presence of long lesion, TCAR appears to be safer than TFCAS with regard to the risk of in-hospital stroke/death, stroke, death, stroke/TIA, and ELOS. These favorable outcomes further confirm superiority of flow reversal compared to distal embolic protection (DEP) devices in terms of neuroprotection since, with TFCAS, it is hazardous passing the DEP through the long carotid lesions. TFCAS mandates lesion manipulation prior to protection, while TCAR offers complete protection prior to any lesion manipulation.

Table 1. In-hospital outcomes of patients with long vs short lesions, stratified by stent approach
TFCAS (Long vs short lesions)TCAR (Long vs short lesions)
aOR (95%CI)P valueaOR (95%CI)P value
Stroke/Death1.3 (1.05-1.7)0.0191.6 (1.3-2.06)<0.001
Stroke/TIA1.3 (1.02-1.7)0.0331.5 (1.2-1.9)0.001
Stroke1.4 (1.01-1.9)0.0461.6 (1.2-2.1)0.001
Death1.2 (0.8-1.6)0.3341.5 (0.96-2.3)0.074
ELOS1.1 (0.97-1.3)0.1311.1 (0.97-1.2)0.172

Table 2. In-hospital outcomes of TCAR vs TFCAS among patients with long lesions
TFCAS(Long lesions)(n=6,401 )TCAR(Long lesions)(n=9,441 )TCAR vs TFCAS(Long lesions)
N (%)N (%)P valueaOR (95%CI)P value
227 (3.5)187 (1.98)<0.0010.6 (0.5-0.8)<0.001
216 (3.4)213 (2.3)<0.0010.7 (0.6-0.9)0.015
148 (2.5)152 (1.6)<0.0010.7 (0.5-0.9)0.009
105 (1.6)51 (0.5)<0.0010.3 (0.2-0.4)<0.001
2,466 (38.5)2,852 (30.2)<0.0010.7 (0.6-0.8)<0.001

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