Urgent/emergent carotid revascularization is associated with an increase in stroke and mortality

Document Type

Article

Publication Date

7-10-2025

Institution/Department

Surgery

Journal Title

Journal of vascular surgery

Abstract

OBJECTIVE: Despite few clinical indications, numerous urgent or emergent carotid procedures have been recorded in the Vascular Quality Initiative (VQI) database. As such, we sought to assess outcomes of urgent and emergent carotid revascularization in the VQI. METHODS: We identified all patients who underwent carotid revascularization in the VQI from 2011-2024. Patients were stratified by urgency status, preoperative symptom status, and procedure type. Elective revascularization was defined by the VQI as a planned/scheduled procedure, urgent as surgery within 24 hours, and emergent as surgery within 6 hours. We excluded patients whose primary procedure was a planned intracranial treatment, as well as patients presenting with trauma, dissection or other nonatherosclerotic indications. The primary outcome was perioperative stroke/death. Secondary outcomes included perioperative death and stroke. Chi-square and logistic regression were used to evaluate perioperative outcomes. RESULTS: Of the 317,163 carotid revascularizations were performed, of which 268,091 (84%) were elective, 45,021 (14%) were urgent, and 4,051 (1%) were emergent. Most urgent(29,958, 67%) or emergent (2,956, 73%) cases were symptomatic, although there were 15,063 (34%) urgent and 1,095 (27%) emergent, asymptomatic procedures. Stroke was the indication for 44% of urgent procedures and 62% of emergent procedures. There 45,021 cases classified as urgent, of which 28,063(62%) were CEA, 8,172 (18%) TCAR, and 8786 (19.5%) tfCAS. Of the 4,051 emergent procedures, 1,235 (31%) were CEA, 182 (4.5%) TCAR, and 2,634 (65%) tfCAS. Compared to elective procedures, among all patients, urgent procedures were associated with increased odds of stroke/death (3.2% vs. 1.2%; aOR 1.99[95% CI 1.80-2.18] P< .01), as were emergent procedures (10.4% vs. 1.2%; aOR: 3.67[3.03-4.44] P< .01). These differences were also noted following subset analyses of asymptomatic (urgent: 3.0% vs. 1.0%; aOR: 2.52[2.16-2.92] P< .01) and (emergent: 9.9% vs. 1.0%; aOR: 5.5[3.91-7.63] P< .01) and symptomatic patients (urgent: 3.3% vs. 1.7%; aOR: 1.65[1.46-1.86] P< .01) and (emergent: 11% vs. 1.7%; aOR: 3.07 [2.43-3.86] P< .01). These differences persisted after stratifying by procedure type, for both asymptomatic and symptomatic patients. CONCLUSION: Urgent or emergent carotid revascularization was associated with higher odds of perioperative stroke/death, stroke, and death. Given the increased risk of urgent or emergent surgery, careful consideration should be given when assessing patients who may ostensibly benefit from expedited surgery, where possible.

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