UC San Diego

BACKGROUND: Postoperative stroke and myocardial infarction (MI) are associated with devastating postoperative morbidity and mortality, therefore limiting the protective effect of carotid revascularization procedures. Moreover, there seems to be a relationship between the severity of stroke and the type of carotid revascularization technique. We aim to investigate the impact of in-hospital stroke or MI on 1-year survival following carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR). METHODS: This is a retrospective analysis of patients undergoing CEA, TFCAS, and TCAR in the vascular quality initiative (VQI) database (2016-2023). Our primary outcome was 1-year mortality in patients who developed in-hospital stroke or MI following carotid revascularization. Kaplan-Meier survival estimate and multivariable Cox regression analysis were applied to calculate hazard ratios (HRs) after adjusting for potential confounders. Additionally, we conducted sub-analyses based on patients' symptomatic status. RESULTS: Our study included 125,513 (61.8%) CEA, 25,875 (12.8%) TFCAS, and 51,545 (25.4%) TCAR patients. Compared to patients who did not have a postoperative stroke, the hazard of 1-year mortality was higher for those who did have a stroke following CEA (adjusted hazards ratio [aHR] = 5.9[95% confidence interval (CI):5.1-6.8] P < 0.001), TFCAS (aHR = 4.2[95% CI: 3.7-5.3] P < 0.001), and TCAR (aHR = 5.2[95% CI: 4.1-6.5] P < 0.001). The hazards of 1-year mortality after in-hospital MI were also higher following CEA (aHR = 3.8[95% CI: 3.1-4.6] P < 0.001), TFCAS (aHR = 3.5[95% CI: 2.3-5.5] P < 0.001), and TCAR (aHR = 5.1[95% CI: 3.6-7.2] P < 0.001). This trend persisted in sub-analysis based on symptomatic status. At 1 year, TFCAS showed the lowest survival following an in-hospital stroke or MI. There was no significant difference in 1-year mortality among patients who developed in-hospital stroke between TCAR and CEA (aHR = 0.93[95% CI: 0.73-1.2] P = 0.55). On the other hand, TFCAS was associated with a 50% higher mortality hazard than CEA (aHR = 1.5[95% CI: 1.1-2.1] P = 0.003), and TCAR was associated with a 30% reduction in 1-year mortality compared to TFCAS (aHR = 0.7[95% CI: 0.55-0.94] P = 0.015) among patients who developed in-hospital stroke. CONCLUSION: This large multicenter study reveals critical insights into the impact of in-hospital major adverse events on 1-year survival following carotid revascularization. The analysis indicates a significant increase in the hazard of 1-year mortality following in-hospital stroke and MI. In patients who developed in-hospital stroke or MI, there was no significant difference in 1-year survival between TCAR and CEA. On the contrary, among patients who developed in-hospital stroke or MI, TFCAS was associated with significantly higher mortality compared to CEA and TCAR. This study highlights the importance of selecting the appropriate revascularization method for each patient to improve 1-year survival.