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.