Impact Of Carotid Lesion Calcification On Outcomes After Transfemoral Vs Transcarotid Artery Stenting
Nadin Elsayed, MD, Kevin S. Yei, BS, Isaac Naazie, MD, MPH, Mahmoud B. Malas, MD, MHS, RPVI, FACS.
University of California San Diego, san diego, CA, USA.
Objectives: The impact of carotid artery lesion calcification on adverse events following carotid artery stenting is not well studied. Few reports associated heavily calcified lesions with high risk of perioperative stroke following transfemoral carotid artery stenting (TFCAS). With the advent of transcarotid artery revascularization (TCAR), we thought to compare the outcomes of these two procedures stratified by the degree of lesion calcification.Methods: Our cohort was derived from the Vascular Quality Initiative (VQI) database for carotid artery stenting. Patients with missing information on the degree of carotid artery calcification were excluded. Patients were stratified into two groups: >50% (severe), and < 50% calcification. Student t-test and chi-square test were used to compare patients’ baseline characteristics and crude outcomes, as appropriate. Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier. Results: A total of 11,342 patients were included. Patients with more severe calcification were older, had more comorbidities, and more contralateral occlusion. There were more patients with prior ipsilateral CEA in the less severe calcification group. In patients who underwent TCAR, there were no significant differences between those who had >50% vs. <50% carotid calcification in the odds of in-hospital adverse outcomes. However, in patients with heavy calcification who underwent TFCAS, there was 50-60% increase in the odds of stroke(OR:1.6, 95%CI:1.04-2.5,P=0.03), stroke/TIA(OR:1.6, 95%CI:1.1-2.3,P=0.013), and stroke/death (OR:1.5, 95%CI:1.02-2.08,P=0.039). In patients with severe calcification and compared to TFCAS, TCAR was associated with 40-70% reduction in the odds of stroke/TIA(OR:0.6, 95%CI:0.38-0.91,P=0.018), death (OR:0.3, 95%CI:0.13-0.72,P=0.006), stroke/death (OR:0.5, 95%CI:0.32-0.8,P=0.004), and stroke/death/MI (OR:0.58, 95%CI:0.39-0.87,P=0.008). There were no significant differences in the odds of stroke and MI (Table 1).Conclusions: The degree of carotid artery calcification has a negative impact on the outcomes of patients undergoing TFCAS. However, it doesn’t appear to impact the outcomes of patients undergoing TCAR. In patients with heavily calcified lesions, TCAR seems to have favorable outcomes compared to TFCAS. These results confirm the superiority of the flow reversal compared to distal embolic protection devices. Further research is needed to assess long-term outcomes and confirm the safety of TCAR in heavily calcified lesions.
| outcomes | TCAR (N=6,926)(>50% vs. <50%) | TFCAS (N=4,416)(>50% vs. <50%) | TCAR vs TFCAS Patients with >50% calcification | |||
| OR (95% CI) | P value | OR (95% CI) | P value | OR (95% CI) | P value | |
| Stroke/death | 1.2 (0.8-1.7) | 0.452 | 1.5 (1.02-2.08) | 0.039 | 0.5 (0.32-0.8) | 0.004 |
| Stroke | 1.2 (0.8-1.8) | 0.406 | 1.6 (1.04-2.5) | 0.032 | 0.69 (0.4-1.1) | 0.140 |
| Death | 0.87 (0.36-2.1) | 0.752 | 1.05 (0.6-1.9) | 0.871 | 0.3 (0.13-0.72) | 0.006 |
| Stroke/TIA | 1.12 (0.8-1.6) | 0.531 | 1.6 (1.1-2.3) | 0.013 | 0.6 (0.38-0.91) | 0.018 |
| Stroke/death/MI | 1.2 (0.81.6) | 0.372 | 1.4 (0.99-2.06) | 0.060 | 0.58 (0.39-0.87) | 0.008 |
| MI | 1.1 (0.6-2.0) | 0.781 | 1.04 (0.5-2.3) | 0.924 | 0.79 (0.37-1.7) | 0.536 |
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