Higher Rate of Reinterventions after Transfemoral Carotid Artery Stenting in Symptomatic Patients: A Retrospective Stroke Center's Cohort Study Between 2015–2024

Background

Carotid artery stenosis is a significant contributor to ischemic strokes, and its surgical management includes carotid artery endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery revascularization (TCAR). CEA has traditionally been preferred, but TF-CAS and TCAR are also excellent alternative options if the anatomy of the vessels allows them. This study reports our short- and mid-term outcomes after carotid artery revascularization in symptomatic patients at a stroke center.

Methods

This single-institution retrospective cohort study was conducted from 2015 to 2024. All patients with focal neurological symptoms attributable to ipsilateral carotid artery stenosis within 6 months before the intervention were included. Primary outcomes were stroke, myocardial infarction (MI), and death within 30 days. Secondary outcomes included mid-term stroke, MI, death, restenosis, and reinterventions. Statistical analyses were performed using R v 4.4.1, and Kaplan-Meier curves were used for sub-group analysis.

Results

A total of 183 interventions on 178 patients were analyzed (TF-CAS = 118, CEA = 55, and TCAR = 10), with a mean age of 71.5 ± 9.6 years. The cohort included 123 male (69.1%) and 55 female (30.9%) patients. Peripheral artery disease (PAD) prevalence was higher in TCAR patients (30.0%) compared to CEA (5.5%) and TF-CAS (5.3%) (P = 0.04). TF-CAS patients had a higher rate of preoperative stroke (68.6%) compared to CEA (50.9%) (P = 0.02); though there was no difference in stroke severity (NIHSS in TF-CAS: 6.8 ± 7.2 vs. CEA: 5.7 ± 7.1; P = 0.86). CEA patients had a higher rate of TIAs (43.6%) than TF-CAS (25.0%) (P = 0.02); but their ABCD2 score did not differ (CEA 3.6 ± 1.6 vs. TF-CAS 3.4 ± 1.5, P = 0.92). Preoperative amaurosis fugax rates were similar (TF-CAS:16.4% vs. CEA 14.4% P = 0.72) among groups. Carotid artery degree of stenosis measured by computed tomography angiography (CTA) was significantly higher in TF-CAS (75.1 ± 17.2) than in CEA (69.6 ± 18.3) (P = 0.01). A vulnerable plaque was found in 60% of CEA and 50% of TF-CAS patients (P = 0.42). TF-CAS had longer hospitalizations than CEA patients (TF-CAS median of 14.0 (IQR: 2.0–16.0) days versus CEA median of 9.0 (IQR 2.0–15.0) days; P < 0.01). Transient cranial nerve injuries occurred in 5.5% of CEA patients but none in TF-CAS patients (P = 0.03). Thirty-day combined ipsilateral stroke, MI and death were 0.0% for CEA and 5.0% for TF-CAS (P = 0.18). Two perioperative deaths occurred among TF-CAS patients, who were older than 70 years of age and with NIHSS of 19 and 8 on presentation. Mid-term follow-up was 1.2 ± 1.4 years. Mid-term combined ipsilateral TIA, stroke, MI, and death were 21.8% for CEA and 22.9% for TF-CAS (P = 0.88). TF-CAS had a higher rate of restenosis (11.0%, P = 0.01) and reintervention (12.7%, P < 0.01) compared to CEA. Reinterventions included cutting-balloon angioplasties, CEA, and TCAR.

Conclusions

TF-CAS is associated with higher, but no significant perioperative mortality, particularly in patients over 70 years of age. Thirty-day and mid-term composite outcomes including ipsilateral stroke, MI, and death are similar in the CEA and TF-CAS groups. However, restenosis occurred more frequently in the TF-CAS group, leading to a higher rate of reintervention, the earliest occurring 2 months after initial intervention. Careful patient selection may mitigate the need for reinterventions in patients undergoing TF-CAS.