Disability and Associated Outcomes Among Patients Suffering Peri-Procedural 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 post-operative stroke remain unclear. Our goal was to assess the degree of disability from a stroke after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) for asymptomatic carotid artery disease, and the associated one-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 post-operative stroke had their disability stratified by modified Rankin score (mRS) of 0-1 (mild), 2-3 (moderate), 4-5 (severe), and 6 (deceased). Post-operative stroke-related disability based on mRS for those recorded at discharge and its association with long-term outcomes were analyzed.

Results: There were 23,435 TCAR and 7,487 TFCAS procedures performed for asymptomatic disease. Among TCAR patients, the periprocedural stroke and stroke/death rates were 0.8% and 1.03%, respectively, with disability distributed as 33.6% mild, 31% 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% moderate, 27.5% severe, and 2.9% deceased. Multivariable analysis demonstrated that severe early postoperative disability was associated with increased one-year mortality (HR 11.04, 95% 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 one-year mortality (HR 1.27, 95% CI 1.10, 1.47, P=.001) and neurological event/death (HR 1.27, 1.11,1.45, P<.001), as compared to 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 (OR 4.2, 95% CI 1.03-17.32, p =0.045), while pre-operative aspirin (OR 0.51, 95% CI 0.30-0.87, p =0.01) or P2Y12 inhibitor use (OR 0.45, 95% CI 0.27-0.74, p=0.11) was associated with a lower likelihood of developing severe disability.

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