Disability and associated outcomes among patients suffering periprocedural strokes after carotid artery stenting

Abstract

Objective: Perioperative stroke after carotid artery stenting (CAS) is rare. However, the degree of disability and long-term effects from a postoperative stroke remain unclear. Our goal was to assess the degree of disability from a stroke after transcarotid artery revascularization (TCAR) and transfemoral CAS (TFCAS) for asymptomatic carotid artery disease, and the associated 1-year impact on subsequent neurological events and mortality.

Methods: The Vascular Quality Initiative CAS registry (2016-2023) was queried for CAS performed for asymptomatic disease. Patients with a postoperative stroke had their disability stratified by modified Rankin score of 0 to 1 (mild), 2 to 3 (moderate), 4 to 5 (severe), and 6 (deceased). Postoperative stroke-related disability based on modified Rankin scale for those recorded at discharge and its association with long-term outcomes were analyzed.

Results: There were 23,435 TCAR and 7487 TFCAS procedures performed for asymptomatic disease. Among TCAR patients, the periprocedural stroke and stroke/death rates were 0.80% and 1.03%, respectively, with disability distributed as 33.6% mild, 31.0% moderate, 28.9% severe, and 7.5% deceased. Among TFCAS patients, the periprocedural stroke and stroke/death rates were 0.92% and 1.19%, respectively, with disability distributed as 37.7% mild, 31.0% moderate, 27.5% severe, and 2.9% deceased. Multivariable analysis demonstrated that severe early postoperative disability was associated with increased 1-year mortality (hazard ratio [HR], 11.04; 95% confidence interval [CI], 6.9-17.7; P = .001) and increased subsequent neurological event/death (HR, 10.82; 95% CI, 6.93-16.9; P = .001). Patients with a stroke after TFCAS had a higher risk of 1-year mortality (HR, 1.27; 95% CI, 1.10, 1.47; P = .001) and neurological event/death (HR, 1.27; 95% CI, 1.11-1.45; P < .001), as compared with patients with a stroke after TCAR. Among patients who undergo a CAS procedure for asymptomatic disease, hypertension was associated with a higher likelihood of developing severe disability (odds ratio [OR], 4.2; 95% CI, 1.03-17.32; P = .045), whereas preoperative aspirin (OR, 0.51; 95% CI, 0.30-0.87; P = .01) or P2Y12 inhibitor use (OR, 0.45; 95% CI, 0.27-0.74; P = .11) was associated with a lower likelihood of developing a severe disability.

Conclusions: The majority of patients who undergo TCAR and TFCAS for asymptomatic carotid artery disease who suffered a periprocedural stroke had substantial disability. Patients with strokes from TFCAS have worse 1-year outcomes as compared with patients with stroke after TCAR. These findings should help to guide patient-provider discussions regarding the surgical management of asymptomatic carotid stenosis and the risks of CAS interventions, as well as aid in the prognostication of postoperative stroke.

Keywords: Carotid artery stenosis; Carotid artery stent; Modified Rankin scale; Periprocedural stroke; Transcarotid artery revascularization; Transfemoral carotid artery stenting.