Exact symptom status better predicts outcomes after transfemoral carotid artery stenting

Marc Schermerhorn

Further stratification according to preprocedural symptoms in patients undergoing transfemoral carotid artery stenting (TFCAS) improves the preoperative risk assessment, a review of the Society for Vascular Surgery (SVS)’s Vascular Quality Initiative (VQI) data suggests.

According to principal author Marc L Schermerhorn (Beth Israel Deaconess Medical Center, Boston, USA), “Most previous studies investigating outcomes after carotid revascularisation stratified the patient population as either symptomatic or asymptomatic; they did not specify the degree of presenting neurologic injury.”

The purpose of the study was to provide and update the contemporary perioperative outcomes after TFCAS stratified by the specific preprocedural symptoms in a real-world setting of a large clinical registry.

As reported in the June issue of the Journal of Vascular Surgery, Schermerhorn’s team studied 9,807 patients who had undergone TFCAS from 2016 to 2020 and are in the VQI database.

Team members stratified patients according to their preprocedural symptom status as asymptomatic, formerly symptomatic, or recently symptomatic. The symptoms included stroke, hemispheric transient ischaemic attack (TIA), and ocular TIA.

The cohort, whose age averaged 70 years (interquartile range, 64–77) had the following preprocedural symptom classifications:

  • Recent (<180d) stroke: 2,650 (27%)
  • Recent hemispheric TIA: 842 (9%)
  • Recent ocular TIA: 360 (4%)
  • Formerly (>180d) symptomatic: 795 (8%)
  • Asymptomatic: 5,160 (53%)

The team observed the perioperative stroke/death rates varying according to symptom status:

  • Recent (<180d) stroke: 5.5%
  • Recent hemispheric TIA: 2.4%
  • Recent ocular TIA: 2.8%
  • Formerly (>180d) symptomatic: 3.5%
  • Asymptomatic: 1.4%

After risk adjustment, the odds ratio for stroke/death were observed to be:

  • Recent stroke versus TIA: 2.6 (p<0.001)
  • Recent stroke versus asymptomatic: 4.1 (p<0.001)
  • Asymptomatic versus formerly symptomatic: 0.4 (p<0.001)

“This study supports the practice of using specific preprocedural symptom status in the preoperative risk assessment of patients undergoing TFCAS,” said Schermerhorn. “Of particular interest is that differentiating between formerly symptomatic (symptoms dating >180d prior to intervention) and asymptomatic patients may allow for greater accuracy in outcomes reporting in future studies.”

Given little error is allowed in the treatment of carotid disease, both symptomatic and asymptomatic, these findings highlight the importance of better stratifying patients preoperatively with regards to symptom status.


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