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Safety And Efficacy Of Carotid Artery Dissection Management With Transfemoral Carotid Artery Stent (TFCAS) And Transcarotid Artery Revascularization (TCAR): Multi-institutional Study.
Ahmed Abdelkarim, MD, Mikayla Kricfalusi, MD, Sina Zarrintan, MD, Elsie Ross, MD, Mahmoud Malas, MD, MHS, RPVI, FACS.
UC San Diego, San Diego, CA, USA.
Introduction: Carotid artery dissection (CD) could lead to stroke, particularly in younger patients. Most studies assessing the safety of carotid artery stenting have excluded patients with dissections. We aim to fill that gap by evaluating and comparing the outcomes of Transfemoral Carotid Artery Stenting (TFCAS) and Transcarotid Artery Revascularization (TCAR) in the management of CD using national database.
Methods: This is a retrospective analysis of all patients who underwent either TFCAS or TCAR for spontaneous carotid dissection in the VQI database from 2016 to 2024. The primary outcomes were 30-day mortality and in-hospital major adverse cardiovascular events (MACE), including stroke, death, and myocardial infarction (MI). Multivariate logistic regression models were employed to adjust for demographics, insurance, smoking, comorbidities, prior procedures, urgency, symptomatic status, and medications.
Results: There were 554 patients treated with TFCAS (387; 69.9%) or TCAR (167; 30.1%) for CD. TCAR patients were older (mean age 67.3 vs. 59.7 years.;P<0.001) with more comorbidities such as CKD (26.8% vs. 13.5%;P<0.001), hypertension (78.4% vs. 68.8%;P=0.02), CAD (41.9% vs. 23.4%;P<0.001),and more likely to be on preoperative medications and undergo general anesthesia (92% vs. 38%;P<0.001) (Table 1). TFCAS patients were more likely to be symptomatic (64.9% vs 43.1%;P<0.001), have a higher ASA class (24% vs. 22%;P<0.001),and undergo urgent intervention (34% vs. 24.6%;P<0.001). Two-stent usage was similar between the two groups (21%TCAR vs. 28%TFCAS; P=0.08). TCAR was associated with lower 30-day mortality (1.2% vs. 2.8%), in-hospital stroke (1.2% vs. 3.2%), MI (0.6% vs. 0.8%), MACE (2.4% vs. 5.7%), reperfusion syndrome (0.6% vs. 2.3%), technical failure (0% vs. 0.5%), access site complications (2.4% vs. 4.9%), and shorter LOS (39.5% vs. 51%). However, these differences were not statistically significant (Table 2).
Conclusions: In this multi-institutional national study, we have demonstrated that both TFCAS and TCAR have acceptable rates of in-hospital stroke and death. Although not statistically significant, the results suggest that TCAR is associated with better technical success and periprocedural outcomes in treating CD compared to TFCAS.
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| Table 1: Baseline Characteristics of Carotid Artery Dissection Patients Undergoing TFCAS and TCAR |
| | TFCAS, 387 (69.9%) | TCAR, 167 (30.1%) | P value |
| Age | 59.680 (15.206) | 67.323 (12.468) | <0.001 |
| Female gender | 169 (43.7%) | 52 (31.1%) | 0.006 |
| Race | | | |
| white | 317 (81.9%) | 139 (83.2%) | 0.708 |
| Non-white | 70 (18.1%) | 28 (16.8%) | |
| Hispanic or Latino | 21 (5.4%) | 7 (4.2%) | 0.5 |
| Smoking status | | | 0.081 |
| Prior | 125 (32.5%) | 64 (38.3%) | |
| Current | 94 (24.4%) | 48 (28.7%) | |
| CKD | 51 (13.5%) | 44 (26.8%) | <0.001 |
| COPD | 49 (12.7%) | 27 (16.2%) | 0.27 |
| DM | 78 (20.2%) | 45 (26.9%) | 0.08 |
| Dialysis | 1 (0.3%) | 2 (1.2%) | 0.17 |
| Hypertension | 265 (68.8%) | 131 (78.4%) | 0.02 |
| Prior CABG-PCI | 65 (16.8%) | 47 (28.1%) | 0.002 |
| Prior CHF | 33 (8.5%) | 12 (7.2%) | 0.6 |
| CAD | 90 (23.4%) | 70 (41.9%) | <0.001 |
| Prior Contralateral CEA/CAS | 30 (7.8%) | 26 (15.6%) | 0.005 |
| Prior Ipsilateral CAS | 23 (5.9%) | 6 (3.6%) | 0.3 |
| Prior Ipsilateral CEA | 67 (17.3%) | 34 (20.4%) | 0.4 |
| Anesthesia | | | <0.001 |
| Local/Regional | 237 (61.6%) | 13 (7.8%) | |
| General | 148 (38.4%) | 154 (92.2%) | |
| ASA class | | | <0.001 |
| III | 190 (52.5%) | 124 (75.2%) | |
| IV-V | 88 (24.3%) | 36 (21.8%) | |
| Symptomatic | 251 (64.9%) | 72 (43.1%) | <0.001 |
| Two-stent Usage | 108 (28%) | 35 (21%) | 0.08 |
| Aspirin | 304 (78.6%) | 141 (84.4%) | 0.11 |
| P2Y2 inhibitor | 277 (71.6%) | 137 (82.0%) | 0.009 |
| Anticoagulant | 41 (10.6%) | 34 (20.4%) | 0.002 |
| Beta-blocker | 122 (31.5%) | 81 (48.5%) | <0.001 |
| Statin | 267 (69.0%) | 141 (84.4%) | <0.001 |
| ACE inhibitor/ ARB | 113 (29.2%) | 67 (40.1%) | 0.012 |
| Urgency | | | <0.001 |
| Elective | 164 (42.6%) | 117 (70.1%) | |
| Urgent | 132 (34.3%) | 41 (24.6%) | |
| Emergent | 89 (23.1%) | 9 (5.4%) | |
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| Table 2: Postoperative outcomes of TCAR vs TFCAS in patients with carotid artery dissection. |
| In-hospital | Univariate | Multivariate |
| All CAS(554) | TFCAS (387) | TCAR (167) | | TCAR vs. TFCAS (TFCAS is Ref) |
| N (%) | N (%) | N (%) | P-value (Fisher''s exact) | Outcomes* | aOR (95% CI) | p-value |
| 30-day mortality | 13 (2.4) | 11(2.8) | 2(1.2) | 0.2 | 30-day mortality | 0.3 (0.05-2.1) | 0.3 |
| In-hospital outcomes | | | | | In-hospital outcomes | | |
| Death | 9 (1.6) | 8(2) | 1(0.6) | 0.2 | | | |
| Stroke | 14 (2.6) | 12 (3.2) | 2 (1.2) | 0.14 | Stroke | 0.5(0.1-2.5) | 0.4 |
| MI | 4 (0.7) | 3 (0.8) | 1 (0.6) | 0.6 | | | |
| Stroke/Death | 22 (4) | 19 (4.9) | 3 (1.3) | 0.06 | Stroke/death | 0.4(0.2-1.3) | 0.15 |
| MACE | 26 (4.7) | 22 (5.7) | 4 (2.4) | 0.06 | MACE | 0.6(0.17-2.4) | 0.5 |
| length of stay >1 | 263 (47.5) | 197 (51) | 66(39.5) | 0.009 | length of stay >1 | 0.8(0.5-1.4) | 0.5 |
| Reperfusion syndrome | 10 (1.8) | 9 (2.3) | 1(0.6) | 0.14 | | | |
| Technical Failure | 2 (0.4) | 2 (0.5) | 0 | 0.5 | | | |
| Access site complication** | 23 (4.2) | 19 (4.9) | 4(2.4) | 0.1 | Access site complication** | 0.4 (0.14-1.24) | 0.12 |
| Post-op Infection | 0 | 0 | 0 | | | | |
| Pseudoaneurysm | 4 (0.7) | 4 (0.9) | 0 | 0.23 | | | |
| Hematoma | 15 (2.8) | 11 (3.2) | 4 (2.4) | 0.5 | | | |
| A-V fistula | 0 | 0 | 0 | | | | |
| MI: myocardial infarction; N: number; CI: confidence interval; MI: myocardial infarction; MACE: in-hospital major adverse cardiac events; N: number; aOR: Adjusted odds ratio. * Adjusting for the following confounders: age, BMI, gender, race, ethnicity, symptomatic status, dialysis, CKD, diabetes, hypertension, smoking, CAD, prior CHF, COPD, CABG/PCI, prior contralateral CEA/CAS, prior ipsilateral CEA/CAS, procedure urgency, anesthesia, ASA class, preoperative medications, living status, insurance **Access site complication is hematoma/bleeding, stenosis/occlusion, infection, pseudoaneurysm, or AV Fistula. |
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