Strokes Occurring After Transfemoral Carotid Artery Stenting Are the Most Lethal and Disabling: A Comparative Analysis of Rankin Scores

Document Type

Conference Proceeding

Publication Date

6-2025

Publication Title

Journal of Vascular Surgery

Abstract

Objective: Although previous studies have compared stroke risk after different carotid revascularization procedures, limited evidence exists on whether all strokes have the same magnitude. This study aims to quantify and compare the severity of strokes after carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) using the modified Rankin Scale (mRS). By evaluating functional outcomes, we provide insights into debilitating and fatal consequences of strokes across these procedures.

Methods: The Vascular Quality Initiative database was queried from September 2016 to August 2024 for patients who suffered a postoperative stroke after their carotid revascularization procedure. The magnitude of the stroke was quantified using mRS 0-6 (0 = stroke with no symptoms and 6 = stroke leading to death). Patients who did not experience stroke after the index procedure were excluded. A severe stroke was defined as one having mRS >4. Multivariable logistic regression modeling was used to predict the likelihood of severe stroke occurrence after TFCAS and TCAR with reference to CEA. Multivariable Cox regression, Kaplan-Meier estimates, and log-rank test analyzed the hazard of mortality as well as the risk of suffering a subsequent ipsilateral stroke within 1 year of the index stroke.

Results: A total of 2752 patients who suffered a postoperative stroke after all three procedures were included in our analysis: CEA 1476 (53.6%), TCAR 748 (27.2%), and TFCAS 528 (19.2%). Overall, 22.5% of the postoperative strokes had mRS >4. When stratifying by procedure type, TFCAS had the highest rate of severe strokes (CEA 21.2% vs TCAR 19.1% vs TFCAS 30.7%, P < .001). After adjusting to confounding variables, postoperative strokes after TCAR and CEA had similar magnitude (mRS > 4: adjusted odds ratio [aOR] = 0.85 [0.67-1.09], P = .200). However, strokes after TFCAS had higher likelihood of being severe (aOR = 1.75 [1.26-2.43], P = .001; aOR = 1.45 [1.05-2.00], P = .024) and lethal (aOR = 1.79 [1.18-2.71], P = .006; aOR = 1.47 [1.03-2.10], P = .036) compared with CEA and TCAR, respectively, especially in symptomatic patients (Table). Similarly, TFCAS had increased hazard of recurrent stroke, death, and stroke/death at 1 year (adjusted hazard ratio [aHR] = 1.29 [1.03-1.61], P = .024; aHR = 1.39 [1.02-1.89], P = .039; aHR = 1.28 [1.04-1.56], P = .018) compared with CEA, whereas no difference was seen in 1-year outcomes of TCAR vs CEA (P > .05). Furthermore, the CEA group demonstrated the highest unadjusted stroke-free survival among the three procedures (Fig).

Conclusions: In this large multi-institutional study, we were able to show that not all postoperative strokes after carotid procedures are the same. Using mRS to quantify the severity of postoperative stroke, we were able to show that strokes after TFCAS were the most disabling and lethal, whereas strokes after TCAR and CEA had similar magnitude postoperatively and up to 1 year of follow-up.

Volume

81

Issue

6

First Page

E251

Last Page

E252

Comments

Society for Vascular Surgery Vascular Annual Meeting (VAM2025), June 4-7, 2025, New Orleans, LA

DOI

10.1016/j.jvs.2025.03.026

ISSN

1531-8249

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