Transcarotid artery revascularization (TCAR) using a flow-reversal neuroprotection system has gained popularity for the endovascular treatment of carotid artery atherosclerotic disease due to its lower risk of stroke or death compared with transfemoral carotid artery stenting. However, specific risk factors associated with stroke or death complications following TCAR have yet to be defined.
All patients undergoing TCAR for treatment of asymptomatic or symptomatic atherosclerotic carotid disease were identified between September 2016 and September 2019 in the Vascular Quality Initiative (VQI) TCAR Surveillance Project. Our primary outcome was 30-day stroke or death. We created a risk model for 30-day stroke or death using multivariable fractional polynomials and internally validated the model using bootstrapping.
During the study period 7,633 patients underwent TCAR, of which 4,089 (53.6%) were treated for symptomatic and 3,544 (46.4%) for asymptomatic disease. The average age of patients undergoing TCAR was 73.3+9.1 years and 63.7% were male. Stroke or death events within 30 days of the index operation occurred in 153 patients (2.0%). Factors independently associated with higher odds of 30-day stroke or death included the severity of presenting stroke symptoms (cortical transient ischemic attack: OR 2.17 [95%CI 1.21-3.90], P = .009; stroke: OR 3.30 [2.25-4.85], P < .001), increasing age (OR 1.03 per year [1.01-1.06], P = .003), and history of unstable angina or myocardial infarction within the past 6 months (OR 2.20 [1.29-3.77], P = .004), moderate or severe congestive heart failure (2.44 [1.31-4.55], P = .005), chronic obstructive pulmonary disease (on medications: OR 1.61 [1.06-2.43], P = .024; on home oxygen: OR 2.52 [1.44-4.41], P = .001), and prior ipsilateral carotid endarterectomy (OR 1.56 [1.09-2.25], P = .016), whereas preoperative P2Y use was associated with a lower odd of 30-day stroke or death (OR 0.57 [0.39-0.85], P = .005). A 30-point risk prediction model created based on these criteria produced a C statistic of 0.72 and Hosmer-Lemeshow goodness of fit of 0.97. Internal validation demonstrated good discrimination with a bias corrected area under the receiver operating characteristic curve of 0.70 with a calibration slope of 1.00.
This VQI TCAR risk score calculator can be used to estimate the risk of stroke or death within 30 days of the procedure. As TCAR is commonly used to treat patients with high surgical risk for carotid endarterectomy, this risk score will help guide treatment decisions in patients being considered for TCAR.
Copyright © 2020. Published by Elsevier Inc.