Outcomes after Transcarotid Artery Revascularization Stratified by Pre-procedural Symptom Status
OBJECTIVE: Previous studies on carotid endarterectomy and transfemoral carotid artery stenting demonstrated that perioperative outcomes differed according to pre-operative neurologic injury severity, but this has not been assessed in transcarotid artery revascularization (TCAR). In this study, we examined contemporary perioperative outcomes in patients who underwent TCAR stratified by specific pre-procedural symptom status. METHODS: Patients who underwent TCAR between 2016-2021 in the Vascular Quality Initiative were included. We stratified patients into the following groups based on pre-procedural symptoms: asymptomatic, recent (symptoms occurring <180 days before>TCAR) ocular transient ischemic attack (TIA), recent hemispheric TIA, recent stroke, or formerly symptomatic (symptoms occurring >180 days before TCAR). First, we used trend tests to assess outcomes in asymptomatic patients vs those with increasing severity of recent neurologic injury (recent ocular TIA vs recent hemispheric TIA vs recent stroke). Then, we compared outcomes between asymptomatic and formerly symptomatic patients. Our primary outcome was in-hospital stroke/death. Multivariable logistic regression was used to adjust for demographics and comorbidities across groups. RESULTS: We identified 18,477 TCAR patients of whom 62% were asymptomatic, 3.2% had recent ocular TIA, 7.6% had recent hemispheric TIA, 18% had recent stroke, and 9.2% were formerly symptomatic. In patients with recent symptoms, we observed higher rates of stroke/death with increasing neurologic injury severity: asymptomatic 1.1% vs. recent ocular TIA 0.8% vs. recent hemispheric TIA 2.1% vs. recent stroke 3.1% (P<.01). In formerly symptomatic patients, the rate of stroke/death was higher compared with asymptomatic patients, but this difference was not statistically significant (1.7% vs. 1.1%; P = .06). After risk adjustment, compared with asymptomatic patients, there was a higher odds of stroke/death in patients with recent stroke (Odds Ratio [OR], 2.8; 95% confidence interval [CI] 2.1-3.7; P<.01), recent hemispheric TIA (OR, 2.0; 95% CI, 1.3-3.0; P<.01), and former symptoms (OR, 1.6; 95% CI, 1.1-2.5; P=.02), but there was no difference in stroke/death in patients with recent ocular TIA (OR, 0.9; 95% CI, 0.4-2.2; P=.78). CONCLUSION: After TCAR, compared with asymptomatic status, recent stroke and recent hemispheric TIA were associated with higher stroke/death, while recent ocular TIA was associated with similar stroke/death. In addition, a formerly symptomatic status was associated with higher stroke/death compared with an asymptomatic status. Overall, our findings suggest that classifying TCAR patients as symptomatic versus asymptomatic may be an oversimplification and that patients' specific pre-operative neurologic symptoms should instead be used in risk assessment and outcome reporting for TCAR.