Association Of Stroke Or Death With Severity Of Carotid Lesion Calcification In Patients Undergoing Carotid Artery Stenting
Lucas Mota, MD1, Sophie X. Wang, MD1, Jack L. Cronenwett, MD2, Brian W. Nolan, MD3, Mahmoud B. Malas, MD4, Marc L. Schermerhorn, MD1, Patric Liang, MD1.
1BIDMC, Boston, MA, USA, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 3Maine Health, Portland, ME, USA, 4UC San Diego, San Diego, CA, USA.
OBJECTIVES: Treatment of circumferentially calcified or bulky carotid lesions with carotid artery stenting (CAS) is controversial given concern for stent failure and increased risk of perioperative stroke, however the degree to which calcification relates to adverse outcomes is poorly described. With the continued increase in the use of transcarotid artery revascularization (TCAR) and its recent expansion to standard surgical-risk patients we aimed to determine the impact of lesion calcification on outcomes following CAS to ensure its safe and appropriate use.
METHODS: We identified patients in the VQI who underwent transfemoral CAS (tfCAS) and TCAR for atherosclerotic disease between 2016-2021. Patients were stratified into four groups based on the degree of lesion calcification: no calcification, 1-50%, 51-99%, and circumferential/protrusion. We used logistic regression and Cox regression to assess the impact of degree of calcification on the primary outcome of in-hospital and 1-year stroke/death, as well as individual outcomes of stroke-death, and myocardial infarction.
RESULTS: Of 21,860 patients identified, 6,177 (28%) patients had no calcification, 7,420 (34%) had 1-50% calcification, 7,665 (35%) had 51-99% calcification, and 598 (3%) had circumferential calcification/protrusion. On adjusted analysis, compared to patients with no calcification, patients with 51-99% calcification and circumferential calcification had higher odds of in-hospital stroke/death (OR 1.30,95%CI 1.02-1.64; OR 1.89,95%CI 1.21-2.94, respectively). Circumferential calcification was also associated with increased risk for in-hospital MI (OR 3.51,95%CI 1.54-8.02). At 1-year, only circumferential calcification was associated with a higher odds of ipsilateral stroke/death (12.4% vs 6.6%,HR 1.64, p=0.002) (Figure). In patients undergoing tfCAS only, circumferential calcification was associated with higher stroke/death odds (OR 1.96, 95%CI 1.15-3.35), while for those undergoing TCAR, 51-99% calcification was associated with increased odds of stroke/death (OR 1.54, 95%CI 1.06-2.24).
CONCLUSIONS: Among patients undergoing CAS, there is an increased risk of in-hospital and 1-year stroke/death when lesions had >50% calcification or circumferential/protruding plaque. This suggests that increasing severity of carotid lesion calcification is a significant risk factor for stroke/death in patients undergoing CAS, regardless of approach. 
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