Hybrid and Total Endovascular Approaches to Tandem Carotid Artery Lesions Have Similar Short- and Long-Term Outcomes

DeCarlo, Charles; Tanious, Adam; Boitano, Laura T.; Mohebali, Jahan; Stone, David H.; Clouse, W. Darrin; Conrad, Mark F.

doi:10.1016/j.avsg.2021.02.027

Cited by 3 publications

(6 citation statements)

References 16 publications

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“…Herein 947 patients undergoing the dual procedure are investigated as opposed to 638 in the largest prior analysis. 10 More importantly, the only prior long-term investigation offered data on only 47 patients beyond one year and just 7 patients beyond 18 months. The expansion and emphasis on the long term follow up component of VQI has now provided 3 year and 5-year survival data on over 450 and 300 patients respectively due to Medicare and SSDI matching.…”

Section: Discussionmentioning

confidence: 99%

“…While long term neurological outcome data is still rather diminutive beyond two years in VQI, the current analysis on this topic is the most robust encountered in an expansive literature search. [4][5][6][7][8]10,[13][14][15][16] Additionally, no prior studies extending beyond the perioperative period have stratified patients with respect to symptomatology. 5,10 This study also expands the perioperative mortality investigation window to 90 days which allows for a more thorough capturing of the effects of adverse perioperative events following CEA with or without concomitant proximal ICA intervention.…”

Section: Discussionmentioning

confidence: 99%

“…[4][5][6][7][8]10,[13][14][15][16] Additionally, no prior studies extending beyond the perioperative period have stratified patients with respect to symptomatology. 5,10 This study also expands the perioperative mortality investigation window to 90 days which allows for a more thorough capturing of the effects of adverse perioperative events following CEA with or without concomitant proximal ICA intervention. Progressive rates of combined neurologic ischemic event and 90-day mortality were observed moving from asymptomatic CEA in isolation (2.2%) at one extreme and combined CEA with proximal CCA intervention for symptomatic stenosis at the opposite extreme (8.8%).…”

Section: Discussionmentioning

confidence: 99%

“…4–8,10,13–16 Additionally, no prior studies extending beyond the perioperative period have stratified patients with respect to symptomatology. 5,10 This study also expands the perioperative mortality investigation window to 90 days which allows for a more thorough capturing of the effects of adverse perioperative events following CEA with or without concomitant proximal ICA intervention.…”

Section: Discussionmentioning

confidence: 99%

“…Prior studies investigating long term outcomes on the tandem procedure have not analyzed individual cohorts based on symptomatology. 10 SVS implementation guidelines on carotid disease management note minimal evidence to guide the clinical scenario of tandem lesions in the proximal CCA and the internal carotid. 11 The guidelines surmise that treatment of symptomatic lesions is indicated and that support for dual intervention for asymptomatic disease is currently unfounded.…”

Section: Introductionmentioning

confidence: 99%

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Carotid Endarterectomy With Simultaneous Proximal Common Carotid Endovascular Intervention is Beneficial for Symptomatic Stenosis and Likely Confers No Advantage for Asymptomatic Lesions

Kolde,

Penton,

et al. 2023

Vasc Endovascular Surg

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Introduction Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its’ management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5 years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis. Methods Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined. Results We noted a statistically significant ( P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90 day mortality and combined neurological event and 90 day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90 day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA. Conclusions Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.

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Section: Discussionmentioning

confidence: 99%