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Predictors Of Postoperative Stroke After Transfemoral Carotid Artery Stenting
Elisa Caron, MD1, Sai Divya Yadavalli, MD
1, Isa Van Galen, MD
1, Jemin Park, MD
1, Camila R. Guetter, MD, MPH
1, Jeremy Darling, MD
1, Randall A. Bloch, MD
2, Roger B. Davis, ScD
1, Katie Shean, MD
3, Douglas W. Jones, MD
4, Mark E. Conrad, MD
2, Jack L. Cronenwett, MD
5, Marc L. Schermerhorn, MD
1.
1Beth Israel Deconess Medical Center, Boston, MA, USA,
2St Elizabeth's Medical Center, Brighton, MA, USA,
3St Elizabeth's Medical Center, Boston, MA, USA,
4UMass Memorial Medical Center, Worcester, MA, USA,
5Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
Objective: A recent Centers for Medicare and Medicaid Services coverage decision approved the use of transfemoral carotid artery stenting (tfCAS) in average risk patients. Given this recent shift, we sought to identify predictors of postoperative stroke in patients undergoing tfCAS.
Methods: We analyzed VQI data from 2011-2023, identifying tfCAS patients treated for atherosclerosis or restenosis. We excluded patients with interventions outside the ICA or bifurcation and those with procedures that were part of an intracranial treatment. We then stratified patients based on in-hospital postoperative stroke status. Baseline characteristics and outcomes were compared using X
2, and predictors of stroke risk were compared using logistic regression. Ten-fold cross validation was used to identify predictors of stroke. The R2 statistic was calculated for this model against the intercept only null model to provide a measure of variable importance.
Results: In our cohort of 29,317 tfCAS patients, 574(2%) patients had a postoperative stroke. Patients who had a postoperative stroke were older, more likely to be female and to be non-white and to have a higher overall comorbidity burden. Overall, factors associated with increased odds of stroke included age >75(aOR1.59,[95%CI1.22-2.09]p=.001), female sex (aOR1.23[1.011.50]p=.04), preoperative stroke (aOR1.58[1.25-2.00]p<.001), contralateral stenosis 80-99%, and contralateral occlusion, circumferential or protruding calcification, hypertension, urgent or emergent surgery, prior CEA, and moderate/severe distal ICA tortuosity. Dual antiplatelet therapy (DAPT) and having a high-volume physician were associated with decreased odds of stroke (Table 1).
After 10-fold cross validation, the most important predictors of postoperative stoke risk were severe distal tortuosity, emergent surgery, uncontrolled hypertension, urgent surgery, preoperative stroke, age >75, prior CEA, moderate distal tortuosity, controlled hypertension, and calcification. DAPT and having a high-volume surgeon were protective.
Conclusion:The identified mediators of stroke risk after tfCAS offer the opportunity to improve patient selection. These data highlight the need to control modifiable factors preoperatively, like hypertension and anti-platelet therapy. Timing of surgery also emerged a strong predictor of stroke, suggesting the need for careful consideration of the need for emergent or urgent surgery. Anatomic considerations such as vessel tortuosity and calcification should also prompt consideration for an alternate revascularization strategy.
Table 1: Mediators of post operative in hospital stroke following tfCAS| | Baseline Characteristics | Stroke rate | P-value | Multivariable mediators of stroke risk | Importance* |
| (N=574) | N (%) | | aOR1 | 95% CI2 | p-value | |
| Age Category | | | | | | | |
| <65 | 125 (21.8%) | 98 (1.8%) | <0.001 | — | — | | — |
| 65-75 | 213 (37.1%) | 146 (1.6%) | | 0.92 | 0.71, 1.21 | 0.5 | — |
| >75 | 236 (41.1%) | 191 (2.9%) | | 1.59 | 1.22, 2.09 | <0.001 | 65.0 |
| Sex | | | | | | | |
| Male | 332 (57.8%) | 251 (1.9%) | 0.0125 | — | — | — | — |
| Female | 242 (42.2%) | 184 (2.4%) | | 1.23 | 1.01, 1.50 | 0.04 | 39.2 |
| Symptom severity | | | | | | | |
| Asymptomatic | 255 (44.4%) | 203 (1.6%) | <0.001 | — | — | — | — |
| Amaurosis | 7 (1.2%) | 7 (2.3%) | | 1.61 | 0.68, 3.22 | 0.2 | — |
| TIA | 55 (9.6%) | 42 (2.2%) | | 1.25 | 0.87, 1.74 | 0.2 | — |
| Stroke | 257 (44.8%) | 183 (3.2%) | | 1.58 | 1.25, 2.00 | <0.001 | 72.6 |
| Contralateral stenosis | | | | | | | |
| 0-49% | 272 (47.4%) | 230 (2.0%) | 0.117 | — | — | — | — |
| 50-69% | 102 (17.8%) | 83 (2.1%) | | 1.08 | 0.83, 1.40 | 0.5 | — |
| 70-79% | 48 (8.4%) | 34 (1.8%) | | 0.99 | 0.67, 1.41 | >0.9 | — |
| 80-99% | 57 (9.9%) | 45 (2.7%) | | 1.45 | 1.03, 2.01 | 0.027 | 41.7 |
| Occluded | 53 (9.2%) | 43 (2.6%) | | 1.51 | 1.06, 2.11 | 0.017 | 45.5 |
| Calcification | | | | | | | |
| None/unknown | 395 (68.8%) | 275 (1.9%) | <0.001 | — | — | — | — |
| >25% | 38 (6.6%) | 35 (2.2%) | | 1.04 | 0.72, 1.48 | 0.8 | — |
| 26-50% | 32 (5.6%) | 28 (1.9%) | | 0.87 | 0.57, 1.28 | 0.5 | — |
| 51-99% | 87 (15.2%) | 76 (2.3%) | | 1.09 | 0.83, 1.41 | 0.5 | — |
| 100%/Into lumen | 22 (3.8%) | 21 (5.0%) | | 1.85 | 1.11, 2.92 | 0.012 | 47.7 |
| Hypertension | | | | | | | |
| No | 43 (7.5%) | 43 (1.3%) | <0.001 | — | — | — | — |
| Controlled | 377 (65.7%) | 377 (2.0%) | | 1.7 | 1.15, 2.60 | 0.01 | 49.1 |
| Uncontrolled | 153 (26.7%) | 153 (3.7%) | | 2.61 | 1.71, 4.09 | <0.001 | 82.6 |
| Anemia | | | | | | | |
| No | 508 (88.5%) | 384 (2.0%) | 0.0015 | — | — | — | — |
| <10 | 61 (10.6%) | 51 (3.3%) | | 1.29 | 0.94, 1.74 | 0.11 | 32.4 |
| Anti platelet | | | | | | | |
| None | 105 (18.3%) | 105 (3.8%) | <0.001 | — | — | | — |
| ASA | 96 (16.7%) | 96 (2.2%) | | 0.73 | 0.52, 1.04 | 0.083 | 33.1 |
| P2Y | 36 (6.3%) | 36 (1.8%) | | 0.68 | 0.38, 1.17 | 0.2 | |
| DAPT | 337 (58.7%) | 337 (1.7%) | | 0.59 | 0.43, 0.83 | 0.002 | 59.5 |
| Beta blocker | | | | | | | |
| No | 263 (45.8%) | 194 (1.9%) | 0.0505 | — | — | — | 31.2 |
| Yes | 309 (53.8%) | 240 (2.2%) | | 1.18 | 0.96, 1.45 | 0.11 | — |
| ACE/ARB | | | | | | | |
| No | 323 (56.3%) | 238 (2.3%) | 0.0635 | 1.19 | 0.97, 1.45 | 0.089 | 32.37 |
| Yes | 249 (43.4%) | 196 (1.9%) | | — | — | — | — |
| Urgency | | | | | | | |
| Elective | 297 (51.7%) | 230 (1.5%) | <0.001 | — | — | — | — |
| Urgent | 172 (30.0%) | 132 (2.9%) | | 1.6 | 1.25, 2.02 | <0.001 | 73.2 |
| Emergent | 104 (18.1%) | 72 (5.3%) | | 2.55 | 1.77, 3.65 | <0.001 | 96.5 |
| Physician Volume | | | | | | | |
| Low | 94 (16.4%) | 64 (2.1%) | 0.01 | 1.41 | 1.01, 1.96 | 0.039 | 39.3 |
| Medium | 363 (63.2%) | 279 (2.3%) | | 1.5 | 1.18, 1.92 | 0.001 | 62.8 |
| High | 117 (20.4%) | 92 (1.6%) | | — | — | — | — |
| Prior CEA | | | | | | | |
| No | 493 (85.9%) | 373 (2.0%) | 0.244 | — | — | — | — |
| Yes | 80 (13.9%) | 62 (2.4%) | | 1.47 | 1.10, 1.95 | 0.008 | 51.5 |
| Distal Tortuosity | | | | | | | |
| Mild | 331 (57.7%) | 328 (1.9%) | <0.001 | — | — | — | — |
| Moderate | 59 (10.3%) | 58 (2.6%) | | 1.49 | 1.10, 1.97 | 0.007 | 51.1 |
| Severe | 49 (8.5%) | 49 (4.5%) | | 2.33 | 1.68, 3.16 | <0.001 | 100 |
| 1 aOR = Adjusted Odds Ratio, 2CI = Confidence Interval, Adjusted for age class, race, sex, symptom severity, ipsilateral stenosis, contralateral stenosis, calcification, diabetes, hypertension, anemia, smoking, medication use, anesthesia, urgency, medication load, physician volume, prior CEA or CAS and distal tortuosity. *Importance= relative measure of variable importance based on the R2 statistic which is calculated against the intercept only null model. This number is returned as a relative measure of variable importance and is scaled out of 100 for clarity.) |
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