Outcomes of Carotid Artery Stenting for Dissection Are Prohibitive

The treatment of flow limiting lesions in the carotid artery for the prevention of stroke has evolved over time. Alternative approach to the transfemoral route to carotid stenting has gained relevance in recent times. It is speculated that transfemoral carotid artery stenting (TFCAS) will become obsolete. However, it is likely to remain useful in unique circumstances and should remain part of the armamentarium of the modern vascular surgeon. One domain in which TFCAS will remain relevant is in the treatment of carotid dissection. The transfemoral route is favored in this setting given the need to reliably identify the true lumen. This is aided by accessing the origin of the carotid artery and preceding length of nondissected vessel. Most flow-limiting carotid lesions are atherosclerotic in etiology. The vast majority of studies that have evaluated the safety of the various modes of carotid intervention have excluded patients with dissections. Accordingly, there are limited data on the outcomes of TFCAS for the treatment of carotid dissection. Prior studies are limited to case reports and series with samples of less than 10 patients. The Society for Vascular Surgery guidelines for the management of carotid dissection acknowledges insufficient data to support the role of carotid stenting in this domain and recommend stenting for patients who remain symptomatic on medical therapy. This is in alignment with recommendations from the European Society for Vascular Surgery and others. In clinical practice, the presence of a dissection flap in the carotid artery can be anxiety laden, thus leaving some practitioners eager to stent the lesion. However, such enthusiasm must be tempered with objective assessment of risk relative to perceived benefit. This is especially important given the benign progression of asymptomatic carotid dissections that has been described in natural history studies. For these reasons, the objective of this study was to evaluate the outcomes of transfemoral carotid stenting for the treatment of carotid dissection from a contemporary large representative cohort of patients. We performed a retrospective analyses of the cohort of all patients in the Vascular Quality Initiative (VQI) who underwent TFCAS for dissection between January 2006 and December 2019. The VQI is a prospective daTabase maintained by the Society for Vascular Surgery for patient safety and quality improvement. The indication for carotid stenting “dissection” was identified directly from the VQI daTabase. Patients with trauma and fibromuscular dysplasia were excluded. Symptomatic status was determined by the reporting physician. The successful use or nonuse of an embolic protection device (EPD) was identified in the daTabase. The outcomes of interest were new ipsilateral periprocedural stroke, myocardial infarction (MI), 30-day mortality as well as the composites of 30-day stroke/death and 30-day stroke/death/MI and length of stay. Periprocedural ipsilateral stroke was defined as new cortical, vertebrobasilar or ocular stroke within 30 days of the procedure. MI was a clinical or electrocardiogram confirmed diagnosis or a critical elevation in troponins. The composite end points of 30-day stroke/death; and 30-day stroke/death/MI were included in accordance with reference clinical trials. Baseline patient characteristics and absolute outcomes were evaluated using χ2, and t tests as appropriate. Risk adjusted analyses were performed using multivariable logistic regression adjusting for clinically relevant variables. There were 608 patients who underwent transfemoral carotid stenting for carotid dissection. Median follow-up duration was of 337 days. The median age was 53 years (interquartile range, 42-66 years). The prevalence of female sex and white race were 47% and 84%, respectively (Table I). The majority of these procedures were performed in patients who were asymptomatic 416 (68.4%). EPD was used in 255 (41.9%) patients. The incidence of new periprocedural ipsilateral stroke was 23.2%. This outcome was 32.9% for asymptomatic patients and 2.1% for symptomatic patients (P < .001). The risk adjusted analyses showed no significant association between EPD use and new ipsilateral stroke (adjusted odds ratio, 0.78; 95% confidence interval, 0.47-1.30; P = .34) as this outcome remained high in patients with (20%) and without (25.5%) EPD use (P = .11). Periprocedural MI was 0.5% and 30-day mortality was 4.4%. The composite of 30-day stroke/death was 25.5% while 30-day stroke/death/MI was 26%. The increase in the composite outcomes were largely driven by the elevated periprocedural stroke (Table II). There were no significant predictors of ipsilateral periprocedural stroke identified. The median length of hospital stay was 4 days (interquartile range, 2-8 days). The majority of carotid stents for dissection in this relatively large contemporary cohort were placed in asymptomatic patients. TFCAS for carotid dissection is associated with prohibitive risk of peri procedural stroke in these patients. The use of EPDs does not mitigate this high risk. The underpinnings of the disparate incidence of stroke between asymptomatic and symptomatic patients deserve further granular evaluation. None the less, the prevalent practice of carotid stenting of asymptomatic carotid dissections should be avoided.Table ICharacteristics of patients who underwent transfemoral carotid stenting for dissection: All patients and within strata of symptoms and (EPD) usePatient characteristicsAll patientsSymptomsEPDAsymptomatic416 (68.4%)Symptomatic192 (31.6%)P valueEPD not used 353 (58%)EPD used 255 (42%)P valueAge in years53 (42-66)53 (43-65)54 (40-68).5350 (41-61)58 (44-71)