The Contemporary Natural History of Medically Managed Asymptomatic Carotid Artery Stenosis

Abstract

Objective:The goal of the present study was to determine the safety of a nonshunting strategy during carotid endarterectomy (CEA), especially for patients with contralateral carotid occlusion or recent stroke.Methods: Data from all the CEAs registered in the Vascular Quality Initiative database between October 2012 and June 2020 were analyzed, excluding surgeons with <10 CEAs registered, concomitant procedures, reinterventions, and incomplete information. According to their rate of shunt use, the participating surgeons were divided into three groups: nonshunters (<5%), selective shunters (5%-95%), and routine shunters (>95%). The primary outcomes of in-hospital stroke, mortality, and combined stroke and death rate were analyzed for symptomatic and asymptomatic patients.Results: A total of 113,296 patients met the study criteria, of whom 31,147 were symptomatic and 82,055 were asymptomatic. Of the 1645 surgeons included, 12.1% were nonshunters, 63.4% were selective shunters, and 24.3% were routine shunters, with 10,557, 71,160, and 31,579 procedures in each group, respectively. On univariable analysis, in-hospital stroke (2.0% vs 1.9% vs 1.6%; P ¼ .17), mortality (0.5% vs 0.4% vs 0.4%; P ¼ .71), and stroke and death rate (2.2% vs 2.1% vs 1.8%; P ¼ .23) were similar among the three groups in the symptomatic cohort (Table ). The asymptomatic cohort also did not show a significant difference for in-hospital stroke (0.9% vs 1.0% vs 0.9%; P ¼ .55), mortality (0.2% vs 0.2% vs 0.2%; P ¼ .64), and stroke and death rate (1.0% vs 1.1% vs 1.0%; P ¼ .43). The multivariate models did not show any differences for the primary outcomes between the groups. On subgroup analysis, the stroke and death rates were similar for patients with contralateral carotid occlusion (3.3% vs 2.5% vs 2.4 %; P ¼ .64) and patients presenting with a recent stroke (2.9% vs 3.4% vs 3.1%; P ¼ .60).Conclusions: The results from the present study support the routine use of a nonshunting strategy as a safe cerebral protection strategy, even for patients with contralateral carotid occlusion or recent stroke.