(IP215) Delineating Contemporary Outcomes of Carotid Revascularization in Younger Patients

Objectives: There are notable differences between young and old patients regarding carotid disease. Younger patients are not well represented in carotid disease research, as such the generalizability of current guidelines and treatment strategies to these patients is uncertain. There is a need to understand optimum treatment strategy in these patients. This study delineates the efficacy of the different carotid revascularization strategies in younger patients.

Methods: We studied patients 55 years or younger who underwent carotid revascularization: carotid endarterectomy (CEA), trans-carotid (TCAR) and trans femoral stenting (TFCAS) in the Vascular Quality Initiative (VQI) from 2017-2024. We applied chi-square and Kruskal Wallis rank sum, Kaplan Meier, logistic and cox regression to analyze stroke and death within 30 days and at 1 year.

Results: Of the 207,181 (123,859 CEA; 52,720 TCAR; 30,602 TFCAS) patients who underwent carotid revascularization in the study period, 10,230 (4.9%) were 55 years or younger (6,012 CEA, 1,415 TCAR, 2,803 TFCAS). Younger patients (55 years or less) were most prevalent in the TFCAS group, relative to CEA and TCAR (9.2% vs 4.9% vs 2.7%, P< 0.001). Focusing on the cohort of patients 55 years or younger, TCAR was more frequently performed in patients who were high risk for CEA than TFCAS (53% vs 30%, P< 0.001). CEA patients were the most likely to be symptomatic, while TFCAS patients were most likely to be treated urgently. (Table I) Multivariable risk adjusted regression showed that TFCAS was significantly associated with higher 30-day stroke (OR=1.72[1.06-2.78]), death (OR=3.85[2.21-6.88]) and stroke/death (OR=2.35[1.62-3.43]) compared to CEA. There was no significant difference in 30-day stroke (OR=1.27 [0.69-2.23]), death (OR=1.77[0.75-3.87]), or stroke/death (OR=1.25 [0.73-2.06]) for TCAR relative to CEA. At 1 year, TFCAS was significantly associated with higher death (HR=2.15[1.65-2.80]) and stroke/death (HR=1.54[1.20-1.98) (Fig1). TCAR was associated with higher 1 year mortality (HR=1.71 [1.13-2.57]) but was not significantly different in 1-year stroke/death (HR=1.18[0.79-1.75]) when compared to CEA.

Conclusions: In the VQI database, the carotid revascularization strategy with the highest proportion of younger patients (aged 55 or less) was TFCAS, but CEA was the most prevalent treatment modality among younger patients. TFCAS was associated with worse 30-day and 1-year outcomes relative to CEA, while TCAR demonstrated a higher 1-year mortality compared to CEA. CEA may be the optimal revascularization strategy for this population.