UC San Diego

Introduction

Recent myocardial infarction (MI) represents a real challenge in patients requiring any vascular procedure. There is currently a lack of data on the effect of preoperative MI on the outcomes of carotid revascularization methodology (carotid enterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR)). This study looks to identify modality-specific outcomes for patients with recent MI undergoing carotid revascularization.

Methods

Data was collected from VQI (2016-2022) for patients with carotid stenosis in the United States and Canada with recent MI (<6 mo.) undergoing CEA, TFCAS, or TCAR. In-hospital outcomes after TFCAS vs CEA and TCAR vs CEA were compared. TCAR vs TFCAS were compared in a secondary analysis. We used logistic regression models to compare the outcomes of these three procedures in patients with recent MI, adjusting for potential confounders. Primary outcomes included 30-day in-hospital rates of stroke, death, and MI. Secondary outcomes included stroke/death, stroke/death/MI, post-operative hypertension, post-operative hypotension, prolonged length of stay (>2 days), and 30-day mortality.

Results

The final cohort included 1,217 (54.2%) CEA, 445 (19.8%) TFCAS, and 584 (26.0%) TCAR cases. Patients undergoing CEA were more likely to have prior CABG/PCI and to use anticoagulant. Patients undergoing TFCAS were more likely to be symptomatic, have prior CHF, COPD, CKD, and undergo urgent operations. Patients undergoing TCAR were more likely to have higher rates of ASA class IV-V, P2Y12 inhibitor, and protamine use. In the univariate analysis, CEA was associated with a lower rate of ipsilateral stroke (P=0.079), death (P=0.002), and 30-day mortality (P=0.007). After adjusting for confounders, TFCAS was associated with increased risk of stroke/death (aOR= 2.69 [95% CI: 1.36-5.35] P=0.005) and stroke/death/MI (aOR=1.67, [95% CI: 1.07-2.60], P=0.025) compared to CEA. However, TCAR had similar outcomes compared to CEA. Both TFCAS and TCAR were associated with increased risk of post-operative hypotension (aOR= 1.62 [95% CI: 1.18-2.23] P=0.003 and aOR= 1.74 [95% CI: 1.31-2.32] P=<0.001, respectively) and decreased risk of post-operative hypertension (aOR= 0.59 [95% CI: 0.36-0.95] P=0.029 and aOR= 0.50 [95% CI: 0.36-0.71] P=<0.001, respectively) compared to CEA.

Conclusion

Although recent MI has been established as a high-risk criterion for CEA and an approved indication for TFCAS, this study showed that CEA is safer in this population with lower risk of stroke/death and stroke/death/MI compared to TFCAS. TCAR had similar stroke/death/MI outcomes in comparison to CEA in patients with recent MI. Further prospective studies are needed to confirm our findings.