Effects of Timing on In-hospital and One-year Outcomes after TransCarotid Artery Revascularization.

Document Type

Article

Publication Date

10-7-2020

Journal Title

Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter

MeSH Headings

TCAR, flow reversal, timing, transCarotid artery revascularization, urgent

Abstract

OBJECTIVE: Current recommendations are to perform carotid endarterectomy (CEA) within two weeks of symptoms due to superior long-term stroke prevention, although urgent CEA within 48-hours has been associated with increased perioperative stroke. With the development and rapid adoption of TransCarotid Artery Revascularization (TCAR), we aim to study the impact of timing on outcomes after TCAR.

METHODS: Symptomatic patients undergoing TCAR in the Vascular Quality Initiative between September 2016 and November 2019 were stratified by time to procedure: urgent (TCAR within 48-hours), early (TCAR between 3-14 days after symptoms), and late (TCAR greater than 14 days after symptoms). Primary outcome was in-hospital rates of stroke/death and evaluated using logistic regression. Secondary outcome was one-year rate of recurrent ipsilateral stroke and mortality, analyzed using Kaplan Meier Survival Analysis.

RESULTS: A total of 2608 symptomatic patients undergoing TCAR were included: 144 urgent (5.52%), 928 early (35.58%), and 1536 (58.90%) late. Patients undergoing urgent intervention had increased risk of in-hospital stroke/death that was driven primarily by increased risk of stroke. No differences were seen in in-hospital death. On adjusted analysis, urgent intervention had a 3-fold increased odds of stroke [OR:2.8, 95%CI:1.3-6.2, p=0.01] and a 3-fold increased odds of stroke/death [OR:2.9, 95%CI:1.3-6.4, p=0.01] when compared to late intervention. Patients undergoing early intervention had comparable risks of stroke [OR:1.3, 95%CI:0.7-2.3, p=0.40] and stroke/death [OR:1.2, 9%CI:0.7-2.1, p=0.48] when compared to late intervention. On subset analysis, the type of presenting symptoms was an effect modifier. Both patients presenting with stroke and patients presenting with transient ischemic attacks (TIA) or amaurosis fugax (AF) had increased risk of stroke/death when undergoing urgent compared to late TCAR: [OR:2.7, 95%CI:1.1-6.6, p=0.04] and [OR:4.1, 95%CI:1.1-15.0, p=0.03] respectively. However only patients presenting with TIA or AF had experienced increased risk of stroke when undergoing urgent compared to late TCAR: [OR:5.0, 95%CI:1.4-17.5, p

CONCLUSION: TCAR has a reduced incidence of stroke when performed 48-hours after onset of symptoms. Urgent TCAR within 48 hours of onset of stroke is associated with a three-fold increased risk of in-hospital stroke/death with no added benefit up to one year after the intervention. Further studies are needed on long-term outcomes of TCAR stratified by timing of the procedure.

ISSN

1097-6809

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