SS02 - Procedural Timing Influences Outcomes of Carotid Revascularization in Patients with Bilateral Carotid Stenosis

Objectives: Approximately 30% of asymptomatic patients undergoing carotid revascularization have significant contralateral stenosis, with higher rates in symptomatic cases. While staged procedures are preferred for bilateral stenosis, evidence regarding the optimal timing between interventions remains limited. We investigated outcomes based on timing intervals between bilateral carotid procedures using VQI database.

Methods: This is a retrospective analysis of carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) done for patients who underwent carotid revascularization after prior contralateral intervention in the VQI database from 2016-2024. The primary endpoint was in-hospital stroke. Splines with knots at 3 and 9 months were used to model the non-linear relationship between procedure interval time and in-hospital stroke risk, with 3 months (median) selected as the reference time point. This approach allows for a smooth estimation of how stroke risk changes over time relative to procedures performed at 3-month time point. Inverse Probability weighting balanced procedure types. We additionally conducted a sub-analysis comparing the slope of the spline effects between procedure types to assess for differences in temporal patterns.

Results: We analyzed 14,802 patients (CEA:60%, TFCAS:10.4%, TCAR:29.6%). The mean time interval between the previous and current procedures was 9.3 months (SD 14.4; median 3 months). Across the entire cohort, procedures performed early ( < 3 months) showed significantly higher odds of in-hospital stroke (OR=2.3;[95%CI:1.5-3.7],P < 0.001) compared to 3-month procedures (Fig I,Table I). This finding persisted when stratifying by procedure type, [CEA (OR=2.07 [95%CI:1.30-3.28],P=0.002) and TCAR (OR=2.70 [95%CI:1.21-6.02],P=0.015)] showing a significant increase in in-hospital stroke risk; while TFCAS showed a similar but non-significant trend (OR=1.94 [95%CI:0.86-4.39],P=0.110). Between 3-9 months, a trend towards risk reduction was observed but was only significant for CEA (OR=0.52 [95%CI:0.28-0.94],P=0.03). Beyond 9 months, the same trend persisted, with CEA showing a borderline protective effect (OR=0.34 [95%CI:0.12-1.00],P=0.049) (Table I). Importantly, the comparative analysis showed no significant differences in timing effects between procedures (all P>0.05), suggesting similar temporal patterns across all approaches.

Conclusions: Our study demonstrated that patients who underwent early carotid revascularization ( < 3 months) following a prior contralateral carotid intervention suffered approximately twice the in-hospital stroke risk compared to those who had the procedure performed at 3 months. Beyond 3 months, a decreasing trend in the stroke risk was observed across all procedures. These findings support staging bilateral carotid interventions with at least a 3-month interval, though procedure selection should be individualized based on patient factors. Further prospective research is needed to confirm these findings.