VESS04 - Strokes Occurring After Transfemoral Carotid Artery Stenting Are the Most Lethal and Disabling: A Comparative Analysis of Rankin Scores

Objectives: While previous studies have compared stroke risk after different carotid revascularization procedures, limited evidence exists on whether all strokes have the same magnitude. This study aims to quantify and compare the severity of strokes after carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral stenting (TFCAS) using the modified Rankin Scale (mRS). By evaluating functional outcomes, we provide insights into debilitating and fatal consequences of strokes across these procedures.

Methods: The Vascular Quality Initiative database was queried from September 2016 to August 2024 for patients who suffered a postoperative stroke after their carotid revascularization procedure. The magnitude of the stroke was quantified using mRS 0-6 (0=stroke with no symptoms; 6=stroke leading to death). Patients who did not experience stroke after the index procedure were excluded. A severe stroke was defined as one having mRS>4. Multivariable logistic regression modelling was used to predict the likelihood of severe stroke occurrence after TFCAS and TCAR with reference to CEA. Multivariable Cox regression, Kaplan Meier estimates and Log-Rank test analyzed the hazard of mortality as well as the risk of suffering a subsequent ipsilateral stroke within one year of the index stroke.

Results: A total of 2,752 patients who suffered a postoperative stroke after all three procedures were included in our analysis: CEA 1,476 (53.6%), TCAR 748 (27.2%), and TFCAS 528 (19.2%). Overall, 22.5% of the postoperative strokes had mRS>4. When stratifying by procedure type, TFCAS had the highest rate of severe strokes (CEA 21.2% vs TCAR 19.1% vs TFCAS 30.7%, p< 0.001). After adjusting to confounding variables, postoperative strokes after TCAR and CEA had similar magnitude [mRS>4: aOR=0.85,(0.67-1.09),p=0.200]. However, strokes after TFCAS had higher likelihood of being severe [aOR=1.75,(1.26-2.43),p=0.001; aOR=1.45,(1.05-2.00),p=0.024] and lethal [aOR=1.79(1.18-2.71),p=0.006; aOR=1.47(1.03-2.10),p=0.036] compared to CEA and TCAR respectively, especially in symptomatic patients(Table-I). Similarly, TFCAS had increased hazard of recurrent stroke, death, and stroke/death at one year [aHR=1.29,(1.03-1.61),p=0.024; aHR=1.39,(1.02-1.89),p=0.039; aHR=1.28,(1.04-1.56),p=0.018] compared to CEA; while no difference was seen in one-year outcomes of TCAR vs CEA(p>0.05). Furthermore, CEA group demonstrated the highest unadjusted stroke-free survival among the three procedures (Fig-1).

Conclusions: In this large multi-institutional study, we were able to show that not all postoperative strokes after carotid procedures are the same. Using mRS to quantify the severity of postoperative stroke, we were able to show that strokes after TFCAS were the most disabling and lethal, while strokes after TCAR and CEA had similar magnitude postoperatively and up to one year of follow-up.