Age but not sex is associated with higher risk of in-hospital stroke or death after carotid artery stenting in symptomatic and asymptomatic carotid stenosis

Sex differences in outcomes of carotid artery stenting

OBJECTIVE

Existing evidence is inconclusive on whether women after carotid artery stenting (CAS) experience worse outcomes than men.

METHODS

The outcomes of women and men were compared using the data from nationwide retrospective registry between 2015 and 2019. The primary outcome was the incidence of ischemic stroke and all-cause death. Secondary outcomes included the incidence of ischemic stroke, all-cause death, acute occlusion, and acute myocardial infarction. Functional outcomes were the achieving an mRS score of 0-1 and 0-2. Outcomes were assessed at 30 days after CAS.

RESULTS

In total, 9792 patients (1330 women, 8862 men; mean age, 73.8 vs 73.5 years, p = 0.17) were analyzed. Symptomatic stenosis was common in men (52.0% vs. 55.1%; p = 0.03), while ≥50% stenosis after CAS was common in women (3.2% vs. 2.0%; p = 0.005). The primary outcome was no significantly difference in women and men (2.0% vs. 1.9%; adjusted odds ratio [aOR], 1.19; 95% confidence interval [95%CI], 0.75-1.88).The incidence of all-cause death was higher in women (0.9% vs. 0.5%; aOR, 2.45; 95%CI, 1.11-5.39). Functional outcomes were significantly less common in women than in men (mRS0-1, 72.6% vs. 74.8%; aOR, 0.77; 95%CI, 0.63-0.95; mRS0-2, 82.1% vs. 85.6%; aOR, 0.76; 95%CI, 0.60-0.95).

CONCLUSIONS

This study suggests that there was no significant sex differences in the incidence of ischemic stroke and all-cause death at 30 days. However, women have higher rate of all-cause death and poorer functional outcomes at 30 days than men.

Association between hospital ownership and patient selection, management, and outcomes after carotid endarterectomy or carotid artery stenting : - Secondary data analysis of the Bavarian statutory quality assurance database

BACKGROUND

This study analyses the association between hospital ownership and patient selection, treatment, and outcome of carotid endarterectomy (CEA) or carotid artery stenting (CAS).

METHODS

The analysis is based on the Bavarian subset of the nationwide German statutory quality assurance database. All patients receiving CEA or CAS for carotid artery stenosis between 2014 and 2018 were included. Hospitals were subdivided into four groups: university hospitals, public hospitals, hospitals owned by charitable organizations, and private hospitals. The primary outcome was any stroke or death until discharge from hospital. Research was funded by Germany's Federal Joint Committee Innovation Fund (01VSF19016 ISAR-IQ).

RESULTS

In total, 22,446 patients were included. The majority of patients were treated in public hospitals (62%), followed by private hospitals (17%), university hospitals (16%), and hospitals under charitable ownership (6%). Two thirds of patients were male (68%), and the median age was 72 years. CAS was most often applied in university hospitals (25%) and most rarely used in private hospitals (9%). Compared to university hospitals, patients in private hospitals were more likely asymptomatic (65% vs. 49%). In asymptomatic patients, the risk of stroke or death was 1.3% in university hospitals, 1.5% in public hospitals, 1.0% in hospitals of charitable owners, and 1.2% in private hospitals. In symptomatic patients, these figures were 3.0%, 2.5%, 3.4%, and 1.2% respectively. Univariate analysis revealed no statistically significant differences between hospital groups. In the multivariable analysis, compared to university hospitals, the odds ratio of stroke or death in asymptomatic patients treated by CEA was significantly lower in charitable hospitals (OR 0.19 [95%-CI 0.07-0.56, p = 0.002]) and private hospitals (OR 0.47 [95%-CI 0.23-0.98, p = 0.043]). In symptomatic patients (elective treatment, CEA), patients treated in private or public hospitals showed a significantly lower odds ratio compared to university hospitals (0.36 [95%-CI 0.17-0.72, p = 0.004] and 0.65 [95%-CI 0.42-1.00, p = 0.048], respectively).

CONCLUSIONS

Hospital ownership was related to patient selection and treatment, but not generally to outcomes. The lower risk of stroke or death in the subgroup of electively treated patients in private hospitals might be due to the right timing, the choice of treatment modality or actually to better structural and process quality.

NO Deficiency Compromises Inter- and Intrahemispheric Blood Flow Adaptation to Unilateral Carotid Artery Occlusion

Carotid artery stenosis (CAS) affects approximately 5-7.5% of older adults and is recognized as a significant risk factor for vascular cognitive impairment (VCI). The impact of CAS on cerebral blood flow (CBF) within the ipsilateral hemisphere relies on the adaptive capabilities of the cerebral microcirculation. In this study, we aimed to test the hypothesis that the impaired availability of nitric oxide (NO) compromises CBF homeostasis after unilateral carotid artery occlusion (CAO). To investigate this, three mouse models exhibiting compromised production of NO were tested: NOS1 knockout, NOS1/3 double knockout, and mice treated with the NO synthesis inhibitor L-NAME. Regional CBF changes following CAO were evaluated using laser-speckle contrast imaging (LSCI). Our findings demonstrated that NOS1 knockout, NOS1/3 double knockout, and L-NAME-treated mice exhibited impaired CBF adaptation to CAO. Furthermore, genetic deficiency of one or two NO synthase isoforms increased the tortuosity of pial collaterals connecting the frontoparietal and temporal regions. In conclusion, our study highlights the significant contribution of NO production to the functional adaptation of cerebrocortical microcirculation to unilateral CAO. We propose that impaired bioavailability of NO contributes to the impaired CBF homeostasis by altering inter- and intrahemispheric blood flow redistribution after unilateral disruption of carotid artery flow.

Sex disparities in outcomes after carotid artery interventions: A systematic review

This systematic review aimed to identify sex-specific outcomes in men and women after carotid endarterectomy (CEA) and carotid artery stenting (CAS), including transfemoral and transcarotid. A search of literature published from January 2000 through December 2022 was conducted using key terms attributed to carotid interventions on PubMed. Studies comparing outcome metrics post intervention (ie, myocardial infarction [MI], cerebral vascular accident [CVA] or stroke, and long-term mortality) among male and female patients were reviewed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Overall, all studies reported low rates of perioperative complications. Among the studies that did not stratify outcomes by the preoperative symptom status, there were no significant sex differences in rates of perioperative strokes or MIs. Two studies, however, noted a higher rate of 30-day mortality in male patients undergoing CEA than in female patients. Analysis of asymptomatic patients undergoing CEA revealed no difference in perioperative MIs (female: 0% to 1.8% v male: 0.4% to 4.3%), similar rates of CVAs (female: 0.8% to 5% v male: 0.8% to 4.9%), and no significant differences in the long-term mortality outcomes. Alternatively, symptomatic patients undergoing CEA reported a higher rate of CVAs in female patients vs. male patients (7.7% v 6.2%) and showed a higher rate of death in female patients (1% v 0.7%). Among studies that did not stratify outcome by symptomatology, there was no difference in the 30-day outcomes between sexes for patients undergoing CAS. Asymptomatic patients undergoing CAS demonstrated similar incident rates across perioperative MIs (female: 0% to 5.9% v male: 0.28% to 3.3%), CVAs (female: 0.5% to 4.1% v male: 0.4% to 6.2%), and long-term mortality outcomes (female: 0% to 1.75% v male: 0.2% to 1.5%). Symptomatic patients undergoing CAS similarly reported higher incidences of perioperative MIs (female: 0.3% to 7.1% v male: 0% to 5.5%), CVAs (female: 0% to 9.9% v male: 0% to 7.6%), and long-term mortality outcomes (female: 0.6% to 7.1% v male: 0.5% to 8.2%). Sex-specific differences in outcomes after major vascular procedures are well recognized. Our review suggests that symptomatic female patients have a higher incidence of neurologic and cardiac events after carotid interventions, but that asymptomatic patients do not.

Assessment of cerebral autoregulatory function and inter-hemispheric blood flow in older adults with internal carotid artery stenosis using transcranial Doppler sonography-based measurement of transient hyperemic response after carotid artery compression

Unhealthy vascular aging promotes atherogenesis, which may lead to significant internal carotid artery stenosis (CAS) in 5 to 7.5% of older adults. The pathogenic factors that promote accelerated vascular aging and CAS also affect the downstream portion of the cerebral microcirculation in these patients. Primary treatments of significant CAS are eversion endarterectomy or endarterectomy with patch plasty. Factors that determine adequate hemodynamic compensation and thereby the clinical consequences of CAS as well as medical and surgical complications of carotid reconstruction surgery likely involve the anatomy of the circle of Willis (CoW), the magnitude of compensatory inter-hemispheric blood flow, and the effectiveness of cerebral microcirculatory blood flow autoregulation. This study aimed to test two hypotheses based on this theory. First, we hypothesized that patients with symptomatic and asymptomatic CAS would exhibit differences in autoregulatory function and inter-hemispheric blood flow. Second, we predicted that anatomically compromised CoW would associate with impaired inter-hemispheric blood flow compensation. We enrolled older adults with symptomatic or asymptomatic internal CAS (>70% NASCET criteria; n = 46) and assessed CoW integrity by CT angiography. We evaluated transient hyperemic responses in the middle cerebral arteries (MCA) after common carotid artery compression (CCC; 10 s) by transcranial Doppler sonography (TCD). We compared parameters reflecting autoregulatory function (e.g., transient hyperemic response ratio [THRR], return to baseline time [RTB], changes of vascular resistance) and inter-hemispheric blood flow (residual blood flow velocity). Our findings revealed that CAS was associated with impaired cerebral vascular reactivity. However, we did not observe significant differences in autoregulatory function or inter-hemispheric blood flow between patients with symptomatic and asymptomatic CAS. Moreover, anatomically compromised CoW did not significantly affect these parameters. Notably, we observed an inverse correlation between RTB and THRR, and 49% of CAS patients exhibited a delayed THRR, which associated with decreased inter-hemispheric blood flow. Future studies should investigate how TCD-based evaluation of autoregulatory function and inter-hemispheric blood flow can be used to optimize surgical techniques and patient selection for internal carotid artery revascularization.

Predictive Factors for Stroke and TIA Following Carotid Artery Stenting

PURPOSE

Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to explore independent risk factors to predict cerebrovascular events following CAS to identify high-risk patients and improve the safety of CAS in this population.

MATERIALS AND METHODS

HISPANIAS is a national prospective multicenter study that included 14 hospitals that collected data from patients who underwent CAS. We analyzed morbidity and mortality within 30 days after CAS, looking for factors that might be associated with cerebrovascular events (stroke and transient ischemic attack [TIA]).

RESULTS

The HISPANIAS cohort included 757 patients: 80.32% were men, the mean age was 70.73 years, and 82.96% underwent symptomatic CAS. Cerebrovascular complications occurred in 42 patients (5.6%), including TIA in 24 patients (70.8% ipsilateral; mean 2.79 days after CAS) and stroke in 18 patients (72.2% ipsilateral; mean 6.72 days after CAS). The main independent clinical predictors of stroke/TIA identified by logistic regression were female sex (odds ratio [OR] 2.29, 95% CI 1.15-4.54) and diabetes (OR 3.29, 95% CI 1.71-6.40). Survival analysis showed that diabetic women, compared with the rest of the patients, had a higher number of events concentrated mainly in the first days after the intervention (p=0.003).

CONCLUSION

Cerebrovascular ischemic complications after CAS continue to be a challenge for the management of these patients. Although there are other factors, female sex and the presence of diabetes are emerging as strong risk factors for the development of complications after symptomatic CAS.

CLINICAL IMPACT

Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. Although CAS has been regarded as a reliable and safety approach, some studies reported that CAS was associated with a higher risk of procedure-related stroke. Cerebrovascular complications after CAS continue to be a main problem and a challenge for the management of these patients. Therefore, it is essential to identify the factors involved in the development of these complications. Our study shows that the combination of female sex and diabetes is associated with a clearly worse outcome, with a greater number of events concentrated mainly in the first days. This is different from other studies that have explored each factor separately. It would be interesting to perform separate interventions for this group given the increased risk of complications.

Transcarotid revascularization outcomes do not differ by patient age or sex

BACKGROUND

Transcarotid artery revascularization (TCAR) is a hybrid approach to carotid revascularization. Limited information is available on the differences in periprocedural complications and performance measures of TCAR for men compared with women and for older vs younger adults.

METHODS

The patient, lesion, and physician characteristics were collected for all TCAR procedures performed by each physician worldwide in an international quality assurance database between March 3, 2009 and May 7, 2020. Clinical composite (ie, death, stroke, transient ischemic attack, myocardial infarction) and technical composite (ie, aborted procedure, conversion to surgery, bleeding, dissection, cranial nerve injury, device failure) adverse events within 24 hours of the procedure were recorded. Four performance measures were recorded: flow-reversal time, fluoroscopy time, contrast volume, and skin-to-skin time. Poisson regressions were used to assess the effects of age and sex on the incidence of clinical and technical composite adverse events. Linear regressions were used to compare the four performance measures.

RESULTS

A total of 18,240 TCARs were performed by 1273 physicians; 34.9% of the patients were women and 37.5% were symptomatic. The overall incidence of clinical and technical composite adverse events was low. The adjusted clinical (1.62% [95% confidence interval (CI), 1.17%-2.23%] vs 1.35% [95% CI, 1.01%-1.79%]; P = .22) and technical (7.84% [95% CI, 6.85%-8.97%] vs 7.80% [95% CI, 6.94%-8.77%]; P = .93) composite adverse event rates did not vary for women vs men. The adjusted clinical (P = .65) and technical (P = .55) composite adverse event rates also did not vary by age. The adjusted skin-to-skin time was shorter for the women (76.6 minutes; 95% CI, 74.6-78.6) than for the men (77.7 minutes; 95% CI, 75.7-79.6; P = .002). Significant differences were found by age group for fluoroscopy time, flow-reversal time, and skin-to-skin time, although the magnitude of these differences was small (<1 minute for each).

CONCLUSIONS

The clinical and technical outcomes of TCAR are not affected by age or sex. We found clinically minor differences in the procedural performance measures when stratified by age and sex. In addition to being safe for younger individuals, TCAR could also be the preferred method for performing carotid stenting in women and older patients, in particular, older women.

Characteristics and outcomes of elderly patients undergoing carotid stenting: Experience of a high-volume interventional cardiology center

BACKGROUND

Carotid artery stenting (CAS) is an attractive option in order to treat carotid artery stenosis. However, its safety in elderly patients is questioned. Aim of this single-center retrospective study was to assess data of elderly patients undergoing CAS, and to compare them with those of the younger (< 75 years).

METHODS

We collected data of 580 consecutive patients undergoing CAS between December 2007 and June 2020 and compared clinical and procedural characteristics as well as in-hospital major adverse events (MACCE) and long-term mortality between patients < 75 years and patients ≥ 75 years old.

RESULTS

There were 272 patients (46.9%) with age ≥ 75 years and 308 patients (53.1%) with age < 75 years. The median follow-up was 48 months (range 2-144). There was no significant difference about in-hospital MACCE between the two groups (4.7% in the older vs. 3.5% in the younger group, p = 0.9), but a higher rate of cerebral hemorrhage occurred in the older group (1.8% vs. = 0.3%, p = 0.07), even if not significant. Long-term mortality was significantly higher in the older group (27.9 vs. 20.1%, p = 0.027). Multivariate predictors of 12-months mortality were neurologic symptoms within 6 months (OR: 4.83; 95% CI: 2.04-11.42; p ≤ 0.001), smoking status (OR: 2.84; 95% CI: 1.17-6.86; p = 0.02) and age ≥ 75 years (OR: 2.78; 95% CI: 1.14-6.76; p = 0.024).

CONCLUSIONS

In elderly patients, CAS can be carried out efficaciously with acceptable procedural risks, if performed by expert operators and after a correct selection by a multidisciplinary team.

Stroke risk and its association with quality of life: a cross-sectional study among Chinese urban adults

BACKGROUND

Stroke is a leading cause of mortality and disability worldwide. Most stroke risk studies focused on more established biological and pathophysiological risk factors such as hypertension and smoking, psychosocial factors such as quality of life are often under-investigated and thus less reported. The current study aims to estimate stroke risk and explore the impact of quality of life on stroke risk among a community sample of urban residents in Shanghai.

METHODS

This cross-sectional study was conducted in Fengxian District of Shanghai City from December 2018 to April 2019. 4030 representative participants were recruited through a multistage, stratified, probability proportional to size sampling method and completed the study. Stroke risk was assessed using the Rapid Stroke Risk Screening Chart that included 8 risk factors for stroke. Quality of life was measured using the World Health Organization Quality of Life-brief version (WHOQOL-BREF).

RESULTS

One-third of residents were at risk for stroke, including 14.39% at high risk, and 18.68% at middle risk. The top three most commonly reported risk factors were physical inactivity (37.30%), hypertension (25.38%), and smoking (17.32%). Quality of life and its four domains were all independently and significantly associated with stroke risk. Multinominal logistic regressions showed that a one-unit increase in the quality of life was associated with a decreased relative risk for middle-risk relative to low-risk of stroke by a factor of 0.988 (95% CI:0.979, 0.997, P = 0.007), and a decreased relative risk for high-risk relative to low-risk of stroke by a factor of 0.975 (95% CI:0.966, 0.984, P < 0.001).

CONCLUSIONS

Our findings showed an alarmingly high prevalence of stroke risk among the sample, which may require future intervention programs to focus on improving both biological and behavioral risk factors such as increasing physical activity, early diagnosis and treatment of hypertension, and smoking cessation, as well as improving psychosocial factors such as quality of life.

Editor's Choice - Distribution of Care and Hospital Incidence of Carotid Endarterectomy and Carotid Artery Stenting: A Secondary Analysis of German Hospital Episode Data

OBJECTIVE

This is a description of the German healthcare landscape regarding carotid artery disease, assessment of hospital incidence time courses for carotid endarterectomy (CEA) and carotid artery stenting (CAS), and simulation of potential effects of minimum hospital caseload requirements for CEA and CAS.

METHODS

The study is a secondary data analysis of diagnosis related group statistics data (2005-2016), provided by the German Federal Statistical Office. Cases encoded by German operation procedure codes for CEA or CAS and by International Classification of Diseases (ICD-10) codes for carotid artery disease were included. Hospitals were categorised into quartiles according to annual caseloads. Linear distances to the closest hospital fulfilling hypothetical caseload requirements were calculated.

RESULTS

A total of 132 411 and 33 709 patients treated with CEA and CAS from 2012 to 2016 were included. CEA patients had lower rates of myocardial infarction (1.4% vs. 1.8%) and death (1.2% vs. 4.0%), and CAS patients were more often treated after emergency admission (38.1% vs. 27.1%). Age standardised annual hospital incidences were 67.2 per 100 000 inhabitants for CEA and 16.3 per 100 000 inhabitants for CAS. The incidence for CEA declined from 2005 to 2016, with CAS rising again until 2016 after having declined from 2010 to 2013. Regarding distance from home to hospital, centres offering CEA are distributed more homogeneously across Germany, compared with those performing CAS. Hypothetical introduction of minimum annual caseloads (> 20 for CEA; > 10 for CAS) imply that 75% of the population would reach their hospital after travelling 45 km for CEA and 70 km for CAS.

CONCLUSION

Differences in spatial distribution mean that statutory minimum annual caseloads would have a greater impact on CAS accessibility than CEA in Germany. Presumably because of a decline in carotid artery disease and a transition towards individualised therapy for asymptomatic patients, hospital incidence for CEA has been declining.

The less invasive paradox, why carotid artery stenting is not suitable for the high-risk patient

Carotid artery stenosis causes significant morbidity and mortality accounting for approximately 8% of all ischaemic strokes. Carotid artery stenting (CAS) offers an endovascular alternative to carotid endarterectomy (CEA), suggested as a viable option in those deemed high-risk for open CEA due to comorbidities or operative technical considerations. A number of large randomised-controlled trials (RCTs) and meta-analysis comparing CAS vs. CEA in unselected patient populations support the conclusion that CAS is associated with a higher risk of stroke and CEA is associated with a higher risk of myocardial infraction. Initial promise for CAS in high-risk patients was demonstrated by The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial that reported CAS was non-inferior to CEA. However, there is evidence to suggest age-related adverse outcome in patients undergoing CAS. There is limited evidence to suggest that CEA could be suitable even in patients deemed high-risk for medical or technical reasons. Further contemporary research on the use of CAS and CEA in high-risk patients is required to re-evaluate current guidelines and high-risk criterion. It is common for a composite outcome of death, ipsilateral stroke and MI which should be questioned as subsequent quality of life is likely to differ after suffering a stroke in comparison to MI. This literature review will discuss the current evidence for CAS and CEA interventions in unselected populations and high-risk patients with carotid disease requiring intervention.

Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review

Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.

An updated systematic review and meta-analysis of results of transcervical carotid artery stenting with flow reversal

OBJECTIVE

Transcervical carotid artery stenting (CAS) has emerged as an alternative to transfemoral CAS. An earlier systematic review from our group (n = 12 studies; 739 transcervical CAS procedures [489/739 with flow reversal]) demonstrated that transcervical CAS is a safe procedure associated with a low incidence of stroke and complications. Since then, new studies have been published adding nearly 1600 patients to the literature. We aimed to update our early systematic review and also to perform a meta-analysis to investigate outcomes specifically after transcervical CAS with flow reversal.

METHODS

An electronic search of PubMed/MEDLINE, Embase, and the Cochrane databases was carried out to identify studies reporting outcomes after transcervical CAS with flow reversal. Crude event rates for outcomes of interest were estimated by simple pooling of data. A proportion meta-analysis was also performed to estimate pooled outcome rates.

RESULTS

A total of 18 studies (n = 2110 transcervical CAS procedures with flow reversal) were identified. A high technical success (98.25%) and a low mortality rate (0.48%) were recorded. The crude rates of major stroke, minor stroke, transient ischemic attack, and myocardial infarction (MI) were 0.71%, 0.90%, 0.57%, and 0.57%, respectively; a cranial nerve injury occurred in 0.28% of the procedures. A neck hematoma was reported in 1.04% of the procedures, and a carotid artery dissection occurred in 0.76% of the interventions; in 1.09% of the cases, conversion to carotid endarterectomy was required. After a meta-analysis was undertaken, the pooled technical success rate was 98.69% (95% confidence interval [CI], 97.19-99.70). A pooled mortality rate of 0.04% (95% CI, 0.00-0.29) was recorded. The pooled rate of any type of neurologic complications was 1.88 (95% CI, 1.24-2.61), whereas the pooled rates of major stroke, minor stroke, and transient ischemic attack were 0.12% (95% CI, 0.00-0.46), 0.15% (95% CI, 0.00-0.50), and 0.01% (95% CI, 0.00-0.22), respectively. The pooled rate of bradycardia/hypotension was 10.21% (95% CI, 3.99-18.51), whereas the pooled rate of MI was 0.08% (95% CI, 0.00-0.39). A neck hematoma after transcervical CAS was recorded in 1.51% (95% CI, 0.22-3.54) of the procedures; in 0.74% (95% CI, 0.05-1.95) of the interventions, conversion to CEA was required. Finally, a carotid artery dissection during transcervical CAS occurred in 0.47% (95% CI, 0.00-1.38) of the procedures.

CONCLUSIONS

This updated systematic review and meta-analysis demonstrated that transcervical CAS with flow reversal is associated with high technical success, almost zero mortality, and low rates of major stroke, minor stroke, MI, and complications.

Sex does not have an impact on perioperative transfemoral carotid artery stenting outcomes among octogenarians

OBJECTIVE

Transfemoral carotid artery stenting (CAS) has been validated as an acceptable alternative to carotid endarterectomy in patients at high risk for open surgery. There are variable sex- and age-based differences in transfemoral CAS outcomes of published randomized controlled trials. The aim of our study was to evaluate sex-based differences in perioperative outcomes after transfemoral CAS performed in octogenarians.

METHODS

The National Surgical Quality Improvement Program targeted vascular module was queried for all patients ≥80 years of age who underwent transfemoral CAS between 2011 and 2017. Symptomatic status was defined as a history of prior ipsilateral stroke, transient ischemic attack, or amaurosis fugax. The primary outcome was a composite outcome of perioperative (30-day) stroke or death. Outcomes were compared for male vs female patients and stratified by symptomatic status using univariate and multivariable logistic regression analyses adjusting for emergent status, symptomatic status, comorbidities, and use of an embolic protection device.

RESULTS

Overall, there were 143 patients ≥80 years of age who underwent transfemoral CAS during the study period, including 95 men (66.4%) and 48 women (33.6%). Race (white, 88.0% vs 85.4%), symptomatic status (30.9% vs 29.2%), and degree of stenosis (severe, 71.6% vs 62.5%) were not significantly different for men vs women (P ≥ .27). Periprocedural stroke/death occurred in six men (6.4%) vs two women (4.2%; P = .59) and did not significantly differ when stratified according to symptomatic (6.9% vs 7.1%; P = .98) and asymptomatic (6.2% vs 2.9%; P = .49) status. Based on multivariable analysis, independent factors associated with the composite end point included emergent vs elective status (adjusted odds ratio OR [aOR], 20.3; 95% confidence interval [CI], 2.25-183) and failure to use an embolic protection device (aOR, 2.86; 95% CI, 1.59-50.0). Sex was not significantly associated with the primary outcome after risk adjustment (aOR, 0.81; 95% CI, 0.28-3.28).

CONCLUSIONS

We found no sex-based differences in risk of perioperative stroke/death among patients ≥80 years of age undergoing transfemoral CAS. Our study validates previous studies showing a high rate of perioperative complications after transfemoral CAS in octogenarians and suggests that the decision to use this technology in older patients should be determined by patients' anatomic and medical risk factors irrespective of sex.

Clinical impact of sex on carotid revascularization

BACKGROUND

The impact of sex in the management of carotid disease is unclear in the current literature. Therefore, we evaluated the effect of sex on perioperative outcomes following carotid endarterectomy (CEA) and carotid artery stenting (CAS).

METHODS

We included patients who underwent CEA or CAS between 2012 and 2017 in the Vascular Quality Initiative database. Our primary outcome was perioperative stroke/death. Secondary outcomes were in-hospital stroke, 30-day mortality, and in-hospital MI. We compared perioperative outcomes between female and male patients, stratified by treatment modality and symptom status, and used multivariable regression to account for differences in baseline characteristics.

RESULTS

A total of 83,436 patients underwent either a CEA (71,383) or CAS (12,053). Asymptomatic and symptomatic CEA females were less likely to be on a preoperative antiplatelet agent, when compared to males. Females overall, were less likely to be on a preoperative statin and more likely to have chronic obstructive pulmonary disease. Within the CAS cohort, females were more likely to have a previous ipsilateral CEA. There were no differences between males and females in major adverse events following CEA for asymptomatic disease. Following CEA for symptomatic disease, there was no difference in stroke/death rate or in-hospital stroke. However, females experienced a higher 30-mortality after adjustment (univariate: 1.0% vs 0.7%, P = .04; adjusted: odds ratio [OR], 1.4:1.02-1.94). Following CAS for asymptomatic disease, females experienced a higher rate of perioperative stroke/death (2.9% vs 1.9% P = .02; OR, 1.5: 1.05-2.03) and in-hospital stroke (2.1% vs 1.2% P = .01; OR, 1.8: 1.20-2.60). There were no differences in outcomes for symptomatic females vs males undergoing CAS.

CONCLUSIONS

Females with carotid disease less frequently receive optimal medical treatment with antiplatelet agents and statins. This is an important target area for quality improvement issue in both females and males. Furthermore, among symptomatic CEA patients the female sex is associated with higher mortality and among asymptomatic CAS patients, females experience higher rates of stroke/death. These findings suggest that careful patient selection is necessary in the treatment of female patients. Quality improvement projects should be created to further investigate and eliminate the disparities of optimal medical management between the sexes.