Abstract
Objective:
Despite few clinical indications, numerous urgent or emergent carotid procedures have been recorded in the Vascular Quality Initiative (VQI) database. As such, we sought to assess outcomes of urgent and emergent carotid revascularization in the VQI.
Methods:
We identified all patients who underwent carotid revascularization in the VQI from 2011-2024. Patients were stratified by urgency status, preoperative symptom status, and procedure type. Elective revascularization was defined by the VQI as a planned/scheduled procedure, urgent as surgery within 24 hours, and emergent as surgery within 6 hours. We excluded patients whose primary procedure was a planned intracranial treatment, as well as patients presenting with trauma, dissection or other nonatherosclerotic indications. The primary outcome was perioperative stroke/death. Secondary outcomes included perioperative death and stroke. Chi-square and logistic regression were used to evaluate perioperative outcomes.
Results:
Of the 317,163 carotid revascularizations were performed, of which 268,091 (84%) were elective, 45,021 (14%) were urgent, and 4,051 (1%) were emergent. Most urgent(29,958, 67%) or emergent (2,956, 73%) cases were symptomatic, although there were 15,063 (34%) urgent and 1,095 (27%) emergent, asymptomatic procedures. Stroke was the indication for 44% of urgent procedures and 62% of emergent procedures. There 45,021 cases classified as urgent, of which 28,063(62%) were CEA, 8,172 (18%) TCAR, and 8786 (19.5%) tfCAS. Of the 4,051 emergent procedures, 1,235 (31%) were CEA, 182 (4.5%) TCAR, and 2,634 (65%) tfCAS. Compared to elective procedures, among all patients, urgent procedures were associated with increased odds of stroke/death (3.2% vs. 1.2%; aOR 1.99[95% CI 1.80-2.18] P<.01), as were emergent procedures (10.4% vs. 1.2%; aOR: 3.67[3.03-4.44] P<.01). These differences were also noted following subset analyses of asymptomatic (urgent: 3.0% vs. 1.0%; aOR: 2.52[2.16-2.92] P<.01) and (emergent: 9.9% vs. 1.0%; aOR: 5.5[3.91-7.63] P<.01) and symptomatic patients (urgent: 3.3% vs. 1.7%; aOR: 1.65[1.46-1.86] P<.01) and (emergent: 11% vs. 1.7%; aOR: 3.07 [2.43-3.86] P<.01). These differences persisted after stratifying by procedure type, for both asymptomatic and symptomatic patients.
Conclusion:
Urgent or emergent carotid revascularization was associated with higher odds of perioperative stroke/death, stroke, and death. Given the increased risk of urgent or emergent surgery, careful consideration should be given when assessing patients who may ostensibly benefit from expedited surgery, where possible.
Keywords: Outcomes, urgency, carotid stenosis, tfCAS, TCAR, CEA, non-elective procedures
INTRODUCTION
Carotid revascularization results in a meaningful reduction in stroke risk, particularly in symptomatic patients.1–3 However, the optimal timing of intervention is debated. The goal of early intervention following a stroke or transient ischemic attack (TIA) is to reduce the risk of recurrent stroke — an outcome that is highest immediately following the first event. Ois et al. found a rate of recurrence following a TIA or mild stroke of 27% in the first 72 hours following symptom onset, while a recent meta-analysis found recurrence rates of 3.5%, 8.0%, and 9.2% following a TIA, at 2, 30, and 90 days, respectively.4,5 To that end, both the Society for Vascular Surgery (SVS) and European Society for Vascular Surgery (ESVS) guidelines recommend revascularization within 14 days of symptoms for patients with carotid stenosis > 50%.6,7 While the ESVS guidelines recommend intervention as soon as possible following symptoms, the SVS suggests intervention after 48 hours.6,7
The role of urgent (within 24 hours) or emergent (within 6 hours) intervention is more controversial, primarily due to concern that the risk of surgery within this period outweighs the benefit. Currently, guidelines suggest emergent surgery only for crescendo TIA (cTIA) or evolving stroke, both of which are relatively uncommon.7 Multiple analyses have shown that intervention within 48 hours is associated with an increased risk of adverse events, including stroke and death.8,9 Despite this, some have argued that the higher procedural risk is acceptable given the high rates of recurrent stroke.10–12 While the guidelines do not recommend urgent or emergent surgery in most cases, many such carotid procedures have been recorded in the Vascular Quality Initiative (VQI) database. In fact, some were performed for asymptomatic patients, for whom there are even fewer indications, such as an unstable-appearing plaque.13,14 Additionally, much of the existing literature defines urgent as procedures occurring within 48 hours, which differs from the VQI definition of 24 hours.8–11,15 However, few have looked at differences within that period. As such, we sought to assess the outcomes of urgent and emergent carotid revascularization in the VQI.
METHODS
Data source and study population
We conducted a retrospective cohort study using the prospectively collected Society for Vascular Surgery VQI (SVS-VQI) Carotid Artery Stent (CAS) and CEA registry data (www.vqi.org). This study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) standards for observational studies.16 This study was approved by the institutional review board at the Beth Israel Deaconess Medical Center, which provided permission to use the data without the need for informed consent, given the retrospective, de-identified nature of the data.
Patient cohort
We identified all carotid revascularizations in the VQI from 2011-2024. We excluded patients whose primary indication for intervention was part of an intracranial treatment, as well as those who were treated for non-atherosclerotic indications. Additionally, to prevent the inclusion of patients being treated for acute stroke rather than carotid stenosis, we also excluded patients without documentation of stent placement as part of their procedure. Patients were stratified by urgency status, preoperative symptoms, and procedure type. The VQI defined an elective procedure as a planned/scheduled procedure, urgent as surgery within 24 hours of admission, and emergent was defined as surgery within 6 hours.17 Within the CAS module, procedures were defined as tfCAS or TCAR based on approach (transfemoral or transcarotid) and use of flow reversal. Patients were then further stratified based on preoperative symptoms.
Variable definitions
Demographics, comorbidities, operative details, and postoperative outcomes were assessed for all patients. In accordance with SVS reporting standards, patients were considered symptomatic if they had any ipsilateral cortical or ocular stroke or TIA within 180 days of the procedure.18 Preoperative symptoms were then further divided into cortical or retinal stroke, hemispheric TIA, and amaurosis fugax. Hypertension was defined as controlled or uncontrolled. Body Mass Index (BMI) was calculated for each patient. Weight categories were defined as the following: underweight (<18.5 kg/m2), normal weight (18.5-25 kg/m2), overweight (25-30 kg/m2), obese (≥30 kg/m2). The preoperative creatinine value was used to estimate the glomerular filtration rate (eGFR) for each patient using the 2021 Chronic Kidney Disease (CKD) Epidemiology Collaboration equation; CKD was then categorized based on eGFR as ≥60, 59-45, 30-44, <30, and dialysis.19,20
The degree of stenosis was based on the highest degree of stenosis from duplex ultrasound, CTA, MRA, or arteriogram, and defined as 0-49%, 50-69%, 70-79%, 80-99%, or occluded. Physician volume was calculated as the number of carotid stenting procedures or CEAs performed over the 12 months preceding each procedure and separated into quintiles. The lowest and highest quintiles were categorized as low (1-6 procedures/year) and high (35-265/year) volume, respectively, while the middle three were classified as medium volume(7-34/year).22,23
The primary outcome was in-hospital stroke/death, which was defined as any ipsilateral carotid territory stroke or death during the index hospitalization. Secondary outcomes included any perioperative stroke and death, and postoperative and overall length of stay.
Statistical analysis
Continuous variables were presented as the mean and standard deviation and compared using the Student’s t-test or Kruskal-Wallis test, as indicated. Categorical variables were presented as counts and percentages and were compared using Pearson χ2. Logistic regression models were then used to assess the association between urgency and outcomes. Our models were adjusted for the following covariates based on statistical or clinical significance: age, sex, race, BMI, smoking history, hypertension, coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, anemia, prior myocardial infarction (MI), prior symptoms (> 6 months), symptom severity (stroke, TIA, amaurosis fugax), degree of ipsilateral and contralateral stenosis, prior CEA or CAS, physician volume and insurance status. Due to a lower number of urgent and emergent TCAR patients after dividing by symptom status, to ensure that the number of beta coefficients were appropriate for the event rate, the model in this subgroup was adjusted for only age, sex, symptom status, degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF, and physician volume. All variables had less than 5% missingness.
All statistical analyses were performed using R, version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria; available at: http://www.r-project.org).
Sensitivity analysis:
We observed a high number of patients undergoing procedures despite an ipsilateral occlusion. Given the possibility that these could represent procedures for acute stroke rather than carotid stenosis, we conducted a sensitivity analysis excluding patients with complete occlusion. Emergent procedures were also more likely to be performed by low volume proceduralists. To further assess the impact of surgeon volume on outcomes for urgent or emergent cases we also analyzed the impact of surgeon volume. A sub analysis of asymptomatic patients who underwent concomitant coronary artery bypass graft (CABG) was also conducted..
RESULTS
Patient characteristics
Between 2011 and 2024, 317,163 carotid revascularizations were performed, of which 268,091 (84%) were elective, 45,021 (14%) were urgent, and 4,051 (1%) were emergent. Most urgent (29,958, 67%) or emergent (2,956, 73%) cases were symptomatic, although there were 15,063 (34%) urgent and 1,095 (27%) emergent, asymptomatic procedures. Stroke was the indication for 44% of urgent procedures and 62% of emergent procedures. There 45,021 cases classified as urgent, of which 28,063(62%) were CEA, 8,172 (18%) TCAR, and 8,786 (19.5%) tfCAS. Of the 4,051 emergent procedures, 1,235 (31%) were CEA, 182 (4.5%) TCAR, and 2,634 (65%) tfCAS.
Patients undergoing urgent or emergent procedures, as compared to elective procedures, were less likely to be of white race (88% elective vs. 83% urgent vs. 81% emergent, P<.01), female (39% vs. 37% vs. 35%, P<.01), were younger (71 years vs. 71 years vs. 69 years, P<.01), and were more likely to be insured with Medicaid (3.6% vs. 5.4% vs. 7.5%, P<.01). Patients undergoing nonelective procedures were also more likely to be current smokers (24% vs. 29% vs. 34%) and to have lower rates of pre-operative ASA (85% vs. 84% vs. 61%), P2Y(53% vs. 54% vs. 33%), anticoagulation (10% vs. 9.4% vs. 7.6%), and statin use (86% vs. 84% vs. 57%) as well as lower use of ACE inhibitors and beta blockers (Table 1).
Table 1:
Baseline characteristics stratified by procedure urgency
| Elective (N=268,091) | Urgent (N=45,021) | Emergent (N=4,051) | P-value | |
|---|---|---|---|---|
|
| ||||
| AGE | ||||
| Mean (SD) | 71.4 (8.84) | 71.0 (9.96) | 68.7 (11.0) | <0.01 |
| Race | ||||
| White | 235,570 (88%) | 37,205 (83%) | 3,268 (81%) | <0.01 |
| Black | 12,696 (4.7%) | 3,075 (6.8%) | 349 (8.6%) | |
| Asian | 2,871 (1.1%) | 568 (1.3%) | 48 (1.2%) | |
| Hispanic | 5,766 (2.2%) | 1,478 (3.3%) | 116 (2.9%) | |
| Other | 10,389 (3.9%) | 2,572 (5.7%) | 258 (6.4%) | |
| Sex | ||||
| Male | 163,641 (61%) | 28582 (64%) | 2,648 (65%) | <0.01 |
| Female | 104,445 (39%) | 16,438 (37%) | 1,403 (35%) | |
| BMI | ||||
| Normal | 5,588 (2.1%) | 1,095 (2.4%) | 112 (2.8%) | <0.01 |
| Underweight | 69,856 (26%) | 11,989 (27%) | 1,004 (25%) | |
| Overweight | 101,468 (38%) | 16,563 (37%) | 1,457 (36%) | |
| Obese | 80,789 (30%) | 13,304 (30%) | 1,237 (31%) | |
| Morbidly Obese | 10,013 (3.7%) | 1,881 (4.2%) | 195 (4.8%) | |
| Procedure | ||||
| tfCAS | 27,862 (10%) | 8,786 (20%) | 2,634 (65%) | <0.01 |
| TCAR | 61,478 (23%) | 8,172 (18%) | 182 (4.5%) | |
| CEA | 178,751 (67%) | 28,063 (62%) | 1,235 (31%) | |
| Symptom Severity | ||||
| Asymptomatic | 208,613 (78%) | 15,063 (34%) | 1,095 (27%) | <0.01 |
| Amaurosis | 10,521 (3.9%) | 2,564 (5.7%) | 77 (1.9%) | |
| TIA | 17,534 (6.5%) | 7,614 (16.9%) | 349 (8.6%) | |
| Stroke | 31,423 (12%) | 19,780 (43.9%) | 2,530 (63%) | |
| Rankin | ||||
| 0 | 233,138 (87%) | 27,410 (61%) | 2,022 (50%) | <0.01 |
| 1 | 18,081 (6.7%) | 6,966 (16%) | 381 (9.4%) | |
| 2 | 8,073 (3.0%) | 4,128 (9.2%) | 319 (7.9%) | |
| 3 | 4,853 (1.8%) | 3,304 (7.3%) | 387 (9.6%) | |
| 4 | 3,634 (1.4%) | 2,837 (6.3%) | 647 (16%) | |
| 5 | 312 (0.1%) | 376 (0.8%) | 295 (7.3%) | |
| Symptoms >6months | 10,863 (4.1%) | 1,047 (2.3%) | 53 (1.3%) | <0.01 |
| Ipsilateral Stenosis | <0.01 | |||
| 0-49% | 9,879 (3.7%) | 2,638 (5.9%) | 177 (4.4%) | |
| 50-69% | 34,350 (13%) | 7,390 (16%) | 341 (8.4%) | |
| 70-79% | 90,915 (34%) | 12,023 (27%) | 516 (13%) | |
| 80-99% | 117,922 (44%) | 19,876 (44%) | 1,494 (37%) | |
| Occluded | 2,695 (1.0%) | 1,368 (3.0%) | 1,278 (32%) | |
| Contralateral Stenosis | <0.01 | |||
| 0-49% | 131,421 (49%) | 23,792 (53%) | 1,999 (49%) | |
| 50-69% | 56,827 (21 %) | 8,127 (18%) | 539 (13%) | |
| 70-79% | 24,543 (9.2%) | 3,486 (7.7%) | 234 (5.8%) | |
| 80-99% | 15,453 (5.8%) | 2,973 (6.6%) | 277 (6.8%) | |
| Occluded | 12,013 (4.5%) | 2,433 (5.4%) | 241 (5.9%) | |
| Prior CEA or CAS | 14,976 (5.6%) | 2,033 (4.5%) | 248 (6.1%) | <0.01 |
| Diabetes | <0.01 | |||
| Diet controlled | 13,025 (4.9%) | 2238 (5.0%) | 205 (5.1%) | |
| Medication controlled | 52,131 (19%) | 8,310 (19%) | 624 (15%) | |
| Insulin controlled | 35,187 (13%) | 6,663 (15%) | 519 (13%) | |
| Hypertension | <0.01 | |||
| Controlled | 120,141 (45%) | 19,045 (42%) | 1,899 (47%) | |
| Uncontrolled | 22,951 (8.6%) | 6,140 (14%) | 544 (13%) | |
| CKD | <0.01 | |||
| GFR=>60 | 168,456 (63%) | 30,547 (68%) | 2,679 (66%) | |
| GFR 45-59 | 48,386 (18%) | 7,005 (16%) | 646 (16%) | |
| GFR30-44 | 31,766 (12%) | 4,529 (10%) | 390 (9.6%) | |
| GFR=<30 | 14,212 (5.3%) | 2,108 (4.7%) | 211 (5.2%) | |
| Dialysis | 2,867 (1.1%) | 641 (1.4%) | 51 (1.3%) | |
| COPD | <0.01 | |||
| Not treated | 204,419 (76%) | 35,090 (78%) | 3,311 (82%) | |
| On medication | 17,216 (6.4%) | 2,707 (6.0%) | 205 (5.1%) | |
| Home O2 | 39,748 (15%) | 6,111 (14%) | 466 (12%) | |
| CAD | 97,412 (36%) | 15,455 (34%) | 1,306 (32%) | <0.01 |
| CHF | <0.01 | |||
| NYHA I & II | 31,056 (12%) | 5168 (12%) | 372 (9.2%) | |
| NYHA III& IV | 4,771 (1.8%) | 1304 (2.9%) | 94 (2.3%) | |
| Smoking | ||||
| Never | 70,529 (26%) | 14,192 (32%) | 1,342 (33%) | <0.01 |
| Prior | 132,353 (49%) | 17,743 (39%) | 1,302 (32%) | |
| Current | 65,023 (24%) | 13,030 (29%) | 1,381 (34%) | |
| Anemia | 13,621 (5.1%) | 4,456 (9.9%) | 354 (8.7%) | <0.01 |
| Preop ASA | 228,567 (85%) | 37,910 (84%) | 2,460 (61%) | <0.01 |
| Preop P2Y | 141,912 (53%) | 24,274 (54%) | 1,354 (33%) | <0.01 |
| Preop Statin | 230,254 (86%) | 38,012 (84%) | 2,327 (57%) | <0.01 |
| Preop βblocker | 148,278 (55%) | 22,845 (51%) | 1,683 (42%) | <0.01 |
| Preop ACE/ARB | 142,185 (53%) | 20,850 (46%) | 1,561 (39%) | <0.01 |
| Preop Anticoagulation | 26,286 (9.8%) | 4,234 (9.4%) | 307 (7.6%) | <0.01 |
| Insurance | <0.01 | |||
| Medicare | 172,002 (64%) | 26,422 (59%) | 2,101 (52%) | |
| Medicaid | 9,595 (3.6%) | 2,414 (5.4%) | 304 (7.5%) | |
| Other | 79,963 (30%) | 15,168 (34%) | 1,580 (39%) | |
| Transfer | <0.01 | |||
| No | 259,494 (97%) | 32,207 (72%) | 2,554 (63%) | |
| Hospital | 7,403 (2.8%) | 12,434 (28%) | 1,468 (36%) | |
| Rehab | 867 (0.3%) | 331 (0.7%) | 20 (0.5%) | |
| Concomitant CABG | ||||
| 2,158 (0.8%) | 847(1.9%) | 26 (0.6%) | <0.01 | |
Data presented as n (%) or mean (SD)
Procedural Characteristics
Compared to elective procedures, emergent procedures were more often to be done by low-volume proceduralists (21% vs. 22% vs. 35%, P<.01). For elective and urgent cases the remainder were evenly split between medium and high volume proceduralists, however for emergent cases there were fewer cases done by high volume proceduralists (47% vs. 20% vs 16%). The majority of cases were done under general anesthesia (93% vs. 94% vs. 94% P<.01) Nonelective procedures were longer for each procedure type, with emergent cases having the longest procedure times (Table 2). Nonelective stenting procedures had higher contrast use (48 mL vs. 67 mL vs. 110 mL, P<.01) and higher fluoroscopy time (9 min vs. 14 min vs. 32 min, P<.01), while shunt use was lower in emergent CEAs (32% vs. 33% vs 16%)P<.01). Compared to elective and urgent cases, emergent cases were less likely to use procedural anticoagulation with Heparin or other agents (99% vs. 98% vs. 83%, P<.01). Protamine use was also less common in emergent cases (71%, 64%, and 22%, P<.01). Total length of stay was also shortest for elective patients and increased for urgent and emergent patients (2.9 days vs. 7.6 days vs. 9.6 days, P<.01). Asymptomatic cases were also analyzed for the day the surgery was performed, with 15% of emergent cases occurring on the weekend, compared to only 5.2% of urgent cases and 0.4% of elective cases (Supplemental table 1).
Table 2:
Procedural characteristics stratified by procedure urgency
| Elective | Urgent | Emergent | P-value | |
|---|---|---|---|---|
| (N=268,091) | (N=45,021) | (N=4,051) | ||
| Physician Volume | <0.01 | |||
| Low | 57,399(21%) | 9,815 (22%) | 1,411 (35%) | |
| Medium | 154,339 (58%) | 26,145 (58%) | 1,999 (49%) | |
| High | 56,353 (47%) | 9,061 (20%) | 641 (16%) | |
| Surgery Day | ||||
| Weekday | 266,262 (99%) | 41,776 (93%) | 3,206 (79%) | <0.01 |
| Weekend | 1,829 (0.7%) | 3,245 (7.2%) | 845 (21%) | |
| Procedure Time | 101 (55%) | 105 (58%) | 102 (58%) | <0.01 |
| Anesthesia | <0.01 | |||
| General | 248,723 (93%) | 42,212 (94%) | 3,794 (94%) | |
| Local/regional | 19,096 (7.1%) | 2,748 (6.1%) | 245 (6.0%) | |
| Contrast | 48.2 (47%) | 67.2 (58%) | 110 (67%) | <0.01 |
| Fluoroscopy time | 9.28 (35%) | 14.0 (17%) | 32.2 (46%) | <0.01 |
| Intraoperative Shunt | 85,057 (32%) | 14,796 (33%) | 659 (16%) | <0.01 |
| Intraoperative Anticoagulation | <0.01 | |||
| None | 3,075 (1.1%) | 742 (1.6%) | 684 (17%) | |
| Heparin | 261,793 (98%) | 43,761 (97%) | 3,247 (80%) | |
| Other | 3,039 (1.1%) | 475 (1.1%) | 92 (2.3%) | |
| Protamine | <0.01 | |||
| No | 73,188 (27%) | 15,303 (34%) | 2,198 (54%) | |
| Yes | 190,255 (71%) | 28754 (64%) | 1104 (27%) | |
| Total LOS | 2.90 (33%) | 7.60 (27%) | 9.60 (64%) | <0.01 |
| Post-op LOS | 1.97 (9.6%) | 3.79 (11%) | 6.98 (12%) | <0.01 |
Data presented as n (%) or mean (SD)
Perioperative Outcomes
Compared to elective procedures, among all patients, urgent procedures were associated with higher odds of stroke/death (3.2% vs. 1.2%; aOR 1.99[95% CI 1.80-2.18] P<.01), as were emergent procedures (10.4% vs. 1.2%; aOR: 3.67[3.03-4.44] P<.01). These differences were also noted among asymptomatic (3.0% vs. 1.0%; aOR: 2.52[2.16-2.92] P<.01) and (9.9% vs. 1.0%; aOR: 5.5[3.91-7.63] P<.01) and symptomatic patients (3.3% vs. 1.7%; aOR: 1.65[1.46-1.86] P<.01) and (10.6% vs. 1.7%; aOR: 3.07 [2.43-3.86] P<.01) (Table 3). When stratified further by stroke or TIA, in stroke patients, urgent and emergent procedures were associated with higher odds of stroke/death (3.8% vs. 2.1%; aOR: 1.54[1.34-1.77] P<.01) and (11.7% vs. 2.1.%; aOR: 2.97 [2.30-3.81] P<.01). While stroke/death rates after TIA were lower relative to intervention after stroke, for both urgent and emergent procedures, there were higher odds of stroke/death (2.5% vs. 1.2%; aOR: 2.09[1.66-2.64] P<.01) and (4.5% vs. 1.2.%; aOR: 3.71 [1.79-7.02] P<.01). TCAR and CEA were both associated with lower odds of stroke/death compared to tfCAS in the overall model (TCAR aOR 0.75 [0.67-0.84] P<.01, CEA aOR 0.62[0.56-0.70] P<.01).
Table 3:
Perioperative outcomes stratified by procedure urgency
| Elective | Urgent | Emergent | p-value | Elective vs Urgent | Elective vs Emergent | |||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||
| Overall | (N=268,091) | (N=45,021) | (N=4,051) | aOR | 95% CI | p-value | aOR* | 95% CI | p-value | |
|
| ||||||||||
| Stroke/Death | 1.2% | 3.2% | 10.4% | <0.01 | 1.99 | 1.80-2.18 | <0.01 | 3.67 | 3.03-4.44 | <0.01 |
| Death | 0.3% | 1.1% | 7.2% | <0.01 | 3.13 | 2.62-3.74 | <0.01 | 8.56 | 6.40-11.4 | <0.01 |
| Stroke(any) | 1.0% | 2.5% | 4.5% | <0.01 | 1.76 | 1.58-1.96 | <0.01 | 2.15 | 1.68-2.75 | <0.01 |
|
| ||||||||||
|
Asymptomatic
| ||||||||||
| N=145,659 | N=10,369 | N=901 | ||||||||
|
| ||||||||||
| Stroke/Death | 1.0% | 3.0% | 9.9% | <0.01 | 2.52 | 2.16-2.92 | <0.01 | 5.5 | 3.90-7.63 | <0.01 |
| Death | 0.2% | 1.3% | 7.3% | <0.01 | 4.29 | 3.33-5.49 | <0.01 | 15.7 | 9.81-24.6 | <0.01 |
| Stroke(any) | 0.9% | 2.1% | 3.8% | <0.01 | 2.12 | 1.78-2.52 | <0.01 | 2.71 | 1.66-4.25 | <0.01 |
|
| ||||||||||
|
Symptomatic
| ||||||||||
| N=43,259 | N=21,895 | N=2,426 | ||||||||
|
| ||||||||||
| Stroke/Death | 1.7% | 3.3% | 10.6% | <0.01 | 1.65 | 1.46-1.86 | <0.01 | 3.07 | 2.43-3.86 | <0.01 |
| Death | 0.4% | 1.0% | 7.4% | <0.01 | 2.14 | 1.69-2.71 | <0.01 | 5.37 | 3.75-7.66 | <0.01 |
| Stroke(any) | 1.5% | 2.6% | 4.8% | <0.01 | 1.57 | 1.35-1.82 | <0.01 | 1.89 | 1.37-2.58 | <0.01 |
Adjusted for procedure, age, sex, race, BMI, symptom severity (asymptomatic, amaurosis, TIA, stroke), prior symptoms (> 6 months), degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF, anemia (hemoglobin <10g/dL), prior MI, medication use, anesthesia type, physician volume, and insurance.
Abbreviations: aOR= Adjusted odds ratio, CI=confidence interval, CEA=Carotid Endarterectomy, TCAR=Trans carotid Artery revascularization, tfCAS=Transfemoral carotid artery stenting, TIA= Transient Ischemic Attack, CKD= Chronic Kidney Disease, COPD=Chronic Obstructive Pulmonary Disease, CAD=Coronary Artery Disease, CHF= Congestive Heart Failure, MI= Myocardial Infarction.
Outcomes by procedure
The use of antiplatelet therapy was lower in both urgent and emergent cases in both the TCAR and tfCAS cohorts. In TCAR patients there was lower use of preoperative Aspirin and P2Y inhibitors (90% vs. 89% vs. 84% P=.01 and 90% vs. 84% vs 73%P<.01) (Supplemental Table 2). There were similar patterns in tfCAS (86% vs. 84% vs. 53% P<.001, and 81% vs. 72% vs. 32% P<.001.). In asymptomatic patients undergoing CEA, compared to elective procedures, urgent procedures were associated with higher odds of stroke/death (3.0% vs. 1.0%; aOR 2.54[1.95-3.28] P<.01), as were emergent procedures (9.9% vs. 0.9%; aOR 9.93[5.12-17.8] P<.01) (Table 4). Similarly, there were higher odds of stroke/death in asymptomatic tfCAS patients for both urgent and emergent procedures (4.1% vs. 1.7%; aOR 2.02[1.48-2.71] P<.01, and 13% vs. 1.7%; aOR 5.14[3.30-7.78] P<.01 respectively). In patients undergoing TCAR, there were higher odds of stroke/death in urgent procedures (3.9% vs. 1.1%; aOR 2.97[2.28-3.81] P<.01), but this was not significantly different for emergent procedures (5.0% vs. 1.1%; aOR 1.75[0.10-8.15] P=.60).
Table 4:
Perioperative outcomes in asymptomatic patients stratified by urgency and procedure
| CEA | Elective | Urgent | Emergent | p-value | Elective vs Urgent | Elective vs Emergent | ||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||
| N=208,613 | N=15,063 | N=1,095 | aOR* | 95% CI | p-value | aOR* | 95% CI | p-value | ||
|
| ||||||||||
| Stroke/Death | 1.0% | 3.0% | 9.9% | <0.01 | 2.54 | 1.95, 3.28 | <0.01 | 9.93 | 5.12, 17.8 | <0.01 |
| Death | 0.2% | 1.3% | 7.3% | <0.01 | 4.65 | 3.12, 6.82 | <0.01 | 16.60 | 6.43, 36.9 | <0.01 |
| Stroke(any) | 0.3% | 2.1% | 3.8% | <0.01 | 1.76 | 1.24, 2.44 | <0.01 | 5.75 | 2.19, 12.5 | <0.01 |
|
| ||||||||||
| TCAR ** | N=37,703 | N=2,291 | N=60 | |||||||
|
| ||||||||||
| Stroke/Death | 1.1% | 3.9% | 5.0% | <0.01 | 2.97 | 2.28, 3.81 | <0.01 | 1.75 | 0.10, 8.15 | 0.60 |
| Death | 0.2% | 1.1% | 5.0% | <0.01 | 3.43 | 2.06, 5.51 | <0.01 | 8.24 | 0.44, 42.3 | 0.05 |
| Stroke(any) | 0.9% | 3.2% | 1.7% | <0.01 | 2.99 | 2.24, 3.92 | <0.01 | 2.10 | 0.12, 9.75 | 0.50 |
|
| ||||||||||
| tfCAS | N=15,514 | N=2,340 | N=590 | |||||||
|
| ||||||||||
| Stroke/Death | 1.7% | 4.1% | 13% | <0.01 | 2.02 | 1.48, 2.71 | <0.01 | 5.14 | 3.30, 7.87 | <0.01 |
| Death | 0.3% | 2.1% | 11% | <0.01 | 4.91 | 2.93, 8.26 | <0.01 | 16.10 | 8.43, 30.5 | <0.01 |
| Stroke(any) | 1.4% | 2.7% | 4.7% | <0.01 | 1.61 | 1.12, 2.29 | 0.01 | 2.39 | 1.25, 4.31 | 0.01 |
adjusted for procedure, age, sex, race, BMI, prior symptoms(> 6 months), degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF, anemia(hemoglobin <10g/dL), prior MI, medication use, anesthesia type, physician volume, and insurance.
Due to low event rate, TCAR specific model adjusted for age, sex, degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF, and physician volume.
Abbreviations: aOR= Adjusted odds ratio, CI=confidence interval, CEA=Carotid Endarterectomy, TCAR=Trans carotid Artery revascularization, tfCAS=Transfemoral carotid artery stenting, TIA= Transient Ischemic Attack, CKD= Chronic Kidney Disease, COPD=Chronic Obstructive Pulmonary Disease, CAD=Coronary Artery Disease, CHF= Congestive Heart Failure, MI= Myocardial Infarction.
In symptomatic patients undergoing CEA, compared to elective procedures, urgent procedures were associated with higher odds of stroke/death (3.2% vs. 1.6%; aOR 1.93[1.60-2.34] P<.01), as were emergent procedures (5.4% vs. 1.6%; aOR 2.41[1.15-4.53] P=.01) (Table 5). In analysis of stroke and TIA patients, once again urgent procedures were associated with higher odds of stroke/death (Stroke only: 3.5% vs. 1.9%, aOR 1.64 [1.34-2.00] P<.01; TIA only: 2.3% vs. 1.2%, aOR 2.15 [1.56-2.96] P<.01), as were emergent procedures (Table 6). Similarly, there were higher odds of stroke/death in symptomatic tfCAS patients for both urgent and emergent procedures (4.5% vs. 2.3%, aOR 1.90[1.48-2.46] P<.01, and 13% vs. 2.3%; aOR 3.73[2.68-5.20] P<.01 respectively). There were higher odds of stroke/death in both Stroke and TIA patients in both urgent (4.5% vs. 2.6%, aOR 1.60 [1.22-2.11] P<.01; 2.8% vs. 1.1%, aOR 2.27 [1.35-3.84] P=.002) and emergent patients (13% vs. 2.6%, aOR 3.66 [2.69-5.01] P<.01; and 6.4% vs. 1.1%, aOR 4.18 [1.22-12.1] P=.01). In patients undergoing TCAR, there were higher odds of stroke/death in urgent procedures (3.4% vs. 2.0%; aOR 1.65[1.30-2.08] P<.01), but did not reach significance in emergent procedures (5.0% vs. 2.0%; aOR 2.71[0.81-6.75] P=.06).Similar to CEA and tfCAS, there were increased odds of stroke/death in urgent stroke and TIA patients(3.5% vs. 2.4%, aOR 1.38 [1.04-1.82] P<.01; 3.1% vs. 1.3%, aOR 1.98[1.22-3.15] P=.01) however it did not reach significance in emergent TIA patients undergoing TCAR (Table 6).
Table 5:
Perioperative outcomes in symptomatic patients stratified by urgency and procedure
| Elective | Urgent | Emergent | p-value | Elective vs Urgent | Elective vs Emergent | |||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||
| CEA | N=27,654 | N=13,294 | N=521 | aOR* | 95% CI | p-value | aOR* | 95% CI | p-value | |
|
| ||||||||||
| Stroke/Death | 1.6% | 3.2% | 5.4% | <0.01 | 1.93 | 1.60, 2.34 | <0.01 | 2.41 | 1.15, 4.53 | 0.01 |
| Death | 0.3% | 0.9% | 2.1% | <0.01 | 2.15 | 1.46, 3.16 | <0.01 | 3.63 | 1.11, 9.58 | 0.02 |
| Stroke(any) | 1.4% | 2.6% | 3.5% | <0.01 | 1.87 | 1.52, 2.31 | <0.01 | 1.59 | 0.55, 3.61 | 0.30 |
|
| ||||||||||
| TCAR ** | N=9,265 | N=3,986 | N=80 | |||||||
|
| ||||||||||
| Stroke/Death | 2.0% | 3.4% | 5.0% | <0.01 | 1.65 | 1.30, 2.08 | <0.01 | 2.71 | 0.81, 6.75 | 0.06 |
| Death | 0.4% | 0.9% | 2.5% | 0.003 | 1.83 | 1.12, 2.98 | 0.02 | 4.91 | 0.76, 17.5 | 0.04 |
| Stroke(any) | 1.8% | 2.9% | 2.5% | 0.004 | 1.58 | 1.23, 2.03 | <0.01 | 1.60 | 0.26, 5.21 | 0.50 |
|
| ||||||||||
| tfCAS | N=6,340 | N=4,615 | N=1,825 | |||||||
|
| ||||||||||
| Stroke/Death | 2.3% | 4.5% | 13% | <0.01 | 1.90 | 1.48, 2.46 | <0.01 | 3.73 | 2.68, 5.20 | <0.01 |
| Death | 0.6% | 2.1% | 9.2% | <0.01 | 3.44 | 2.20, 5.56 | <0.01 | 9.60 | 5.67, 16.6 | <0.01 |
| Stroke(any) | 1.9% | 2.9% | 5.6% | <0.01 | 1.56 | 1.17, 2.09 | <0.01 | 2.22 | 1.47, 3.32 | <0.01 |
adjusted for procedure, age, sex, race, BMI, symptom severity, prior symptoms(> 6 months), degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF, anemia (hemoglobin <10g/dL), prior MI, medication use, anesthesia type, physician volume, and insurance.
Due to low event rate, TCAR specific model adjusted for age, sex, symptom severity, degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF, and physician volume.
Abbreviations: aOR= Adjusted odds ratio, CI=confidence interval, CEA=Carotid Endarterectomy, TCAR=Trans carotid Artery revascularization, tfCAS=Transfemoral carotid artery stenting, TIA= Transient Ischemic Attack, CKD= Chronic Kidney Disease, COPD=Chronic Obstructive Pulmonary Disease, CAD=Coronary Artery Disease, CHF= Congestive Heart Failure, MI= Myocardial Infarction.
Table 6:
Perioperative outcomes in stroke and TIA patients stratified by urgency and procedure
| Indication | Elective | Urgent | Emergent | p-value | Elective vs Urgent | Elective vs Emergent | ||||
|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||
| aOR* | 95% CI | p-value | aOR* | 95% CI | p-value | |||||
|
| ||||||||||
| Overall | ||||||||||
| TIA Only | (N=28,055) | (N=10,178) | (N=426) | |||||||
|
| ||||||||||
| Stroke/Death | 337 (1.2%) | 258 (2.5%) | 19 (4.5%) | <0.01 | 2.09 | 1.66, 2.64 | <0.01 | 3.71 | 1.79, 7.02 | <0.01 |
| Death | 77 (0.3%) | 58 (0.6%) | 10 (2.3%) | <0.01 | 1.94 | 1.18, 3.17 | 0.01 | 4.59 | 1.24, 13.2 | 0.01 |
| Stroke(any) | 287 (1.0%) | 220 (2.2%) | 10 (2.3%) | <0.01 | 2.08 | 1.62, 2.67 | <0.01 | 2.78 | 1.11, 5.96 | 0.02 |
|
| ||||||||||
| Stroke Only | (N=31,423) | (N=19,780) | (N=2,530) | |||||||
|
| ||||||||||
| Stroke/Death | 672 (2.1%) | 742 (3.8%) | 295 (12%) | <0.01 | 1.54 | 1.34, 1.77 | <0.01 | 2.97 | 2.30, 3.81 | <0.01 |
| Death | 144 (0.5%) | 256 (1.3%) | 202 (8.0%) | <0.01 | 2.22 | 1.70, 2.92 | <0.01 | 5.54 | 3.75, 8.18 | <0.01 |
| Stroke(any) | 580 (1.8%) | 570 (2.9%) | 131 (5.2%) | <0.01 | 1.42 | 1.22, 1.66 | <0.01 | 1.98 | 1.43, 2.71 | <0.01 |
|
| ||||||||||
|
CEA
| ||||||||||
| TIA Only | (N=18,890) | (N=6,862) | (N=266) | |||||||
|
| ||||||||||
| Stroke/Death | 225 (1.2%) | 160 (2.3%) | 11 (4.1%) | <0.01 | 2.15 | 1.56, 2.96 | <0.01 | 6.33 | 2.36, 14.2 | <0.01 |
| Death | 53 (0.3%) | 34 (0.5%) | 5 (1.9%) | <0.01 | 1.86 | 0.94, 3.61 | 0.07 | 4.76 | 0.25, 26.7 | 0.20 |
| Stroke(any) | 191 (1.0%) | 138 (2.0%) | 7 (2.6%) | <0.01 | 2.2 | 1.55, 3.11 | <0.01 | 5.96 | 2.00, 14.2 | <0.01 |
|
| ||||||||||
| Stroke Only | (N=19,600) | (N=11,754) | (N=498) | |||||||
|
| ||||||||||
| Stroke/Death | 380 (1.9%) | 416 (3.5%) | 34 (6.8%) | <0.01 | 1.64 | 1.34, 2.00 | <0.01 | 2.32 | 1.09, 4.42 | 0.02 |
| Death | 74 (0.4%) | 114 (1.0%) | 15 (3.0%) | <0.01 | 2.03 | 1.34, 3.11 | <0.01 | 4.81 | 1.56, 12.4 | <0.01 |
| Stroke(any) | 332 (1.7%) | 343 (2.9%) | 23 (4.6%) | <0.01 | 1.57 | 1.26, 1.95 | <0.01 | 1.18 | 0.35, 2.93 | 0.70 |
|
| ||||||||||
|
TCAR
| ||||||||||
| TIA Only | (N=4,910) | (N=1,664) | (N=35) | |||||||
|
| ||||||||||
| Stroke/Death | 65 (1.3%) | 52 (3.1%) | 0 (0%) | <0.01 | 1.98 | 1.22, 3.15 | 0.01 | 0 | >0.9 | |
| Death | 12 (0.2%) | 6 (0.4%) | 0 (0%) | 0.63 | 0.87 | 0.19, 3.23 | 0.80 | 0 | >0.9 | |
| Stroke(any) | 58 (1.2%) | 49 (2.9%) | 0 (0%) | <0.01 | 2.15 | 1.31, 3.50 | 0.002 | 0 | >0.9 | |
|
| ||||||||||
| Stroke Only | (N=7,040) | (N=3,526) | (N=75) | |||||||
|
| ||||||||||
| Stroke/Death | 169 (2.4%) | 125 (3.5%) | 6 (8.0%) | <0.01 | 1.38 | 1.04, 1.82 | 0.02 | 3.77 | 1.28, 8.95 | 0.01 |
| Death | 29 (0.4%) | 42 (1.2%) | 3 (4.0%) | <0.01 | 2.55 | 1.46, 4.56 | 0.001 | 13.0 | 2.82, 43.0 | <0.01 |
| Stroke(any) | 154 (2.2%) | 102 (2.9%) | 4 (5.3%) | 0.03 | 1.21 | 0.89, 1.63 | 0.20 | 2.39 | 0.57, 6.74 | 0.20 |
|
| ||||||||||
|
tfCAS
| ||||||||||
| TIA Only | (N=4,255) | (N=1,652) | (N=125) | |||||||
|
| ||||||||||
| Stroke/Death | 47 (1.1%) | 46 (2.8%) | 8 (6.4%) | <0.01 | 2.27 | 1.35, 3.84 | 0.002 | 4.18 | 1.22, 12.1 | 0.01 |
| Death | 12 (0.3%) | 18 (1.1%) | 5 (4.0%) | <0.01 | 6.28 | 1.89, 25.9 | 0.01 | 11.5 | 1.41, 88.7 | 0.02 |
| Stroke(any) | 38 (0.9%) | 33 (2.0%) | 3 (2.4%) | 0.0035 | 2.09 | 1.19, 3.69 | 0.01 | 2.34 | 0.34, 9.50 | 0.30 |
|
| ||||||||||
| Stroke Only | (N=4,783) | (N=4,500) | (N=1,957) | |||||||
|
| ||||||||||
| Stroke/Death | 123 (2.6%) | 201 (4.5%) | 255 (13%) | <0.01 | 1.60 | 1.22, 2.11 | <0.01 | 3.66 | 2.69, 5.01 | <0.01 |
| Death | 41 (0.9%) | 100 (2.2%) | 184 (9.4%) | <0.01 | 2.33 | 1.50, 3.72 | <0.01 | 6.29 | 3.93, 10.3 | <0.01 |
| Stroke(any) | 94 (2.0%) | 125 (2.8%) | 104 (5.3%) | <0.01 | 1.47 | 1.07, 2.03 | 0.02 | 2.59 | 1.76, 3.81 | <0.01 |
Adjusted for procedure, age, sex, race, BMI, degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF, anemia (hemoglobin <10g/dL), prior MI, physician volume
Sensitivity analysis
Overall outcomes after exclusion of patients with ipsilateral occlusion were similar to the primary analysis. Prior to exclusion, patients with complete ipsilateral occlusion were more likely to undergo tfCAS. After the exclusion there were few changes in outcomes for urgent patients, however the stroke/death rate was significantly lower for both asymptomatic (8.4%), and symptomatic (7.9%) emergent procedures (Supplemental Table 3). Analysis based on surgeon volume was similar to prior work which suggested that high volume proceduralists have better outcomes. For urgent procedures the stroke/death rate decreased with increasing surgeon volume for symptomatic patients (4.5% vs 3.34% vs 3.1%, P=.01). For emergent procedures in asymptomatic patients there was a similar pattern (11% vs. 11.6% vs. 6.5%, P =.03) P (Supplemental Table 2). Outcomes in asymptomatic patients who underwent an CEA and concomitant CABG were notable for significantly higher stroke/death in all cohorts, although this was most pronounced in emergent cases (5.2% vs. 5.0% vs. 30% P<.01|Supplemental Table 4).
DISCUSSION
Current SVS guidelines recommend revascularization in surgically fit patients between 3-14 days following neurologic symptoms attributable to >50% carotid stenosis, and a Rankin score of <3. More urgent intervention is recommended only for patients with crescendo TIA and evolving stroke.7 Despite these recommendations, 45,021 (14%) urgent and 4,051 (1%) emergent carotid revascularizations were recorded in the VQI from 2011-2024. This included both symptomatic and asymptomatic patients. Across both asymptomatic and symptomatic patients, urgent and emergent procedures were associated with significantly higher odds of stroke/death relative to elective cases.
There is conflicting literature regarding the optimal timing of intervention in patients with acute stroke or TIA. Pooled analysis from the NASCET and ECST trials demonstrated a 19% absolute risk reduction of recurrent stroke with CEA within 2 weeks of symptoms.24–26 Within that time frame, the risk of recurrence is highest in the week following the first neurologic event. A Canadian study by Ois et al. reported a recurrence rate of 17% in the first 24 hours, 22% in 48 hours, and 25% at 72 hours for patients with a mild stroke or TIA.5 Johnson et al. found lower recurrence rates: 2.7% in 24 hours, 5.3% in 72 hours, 11.5% at 14 days, and 18.8% at 90 days.27 A recent meta-analysis by Wu et al. was similar and reported recurrence rates of 3.5%, 8.0%, and 9.2% following a TIA at 2, 30, and 90 days, respectively.4 While the risk of recurrence is undoubtedly high, the risks of intervention in this period are also considerable.
Given the increased risk of stroke in the acute period, there has been debate as to whether the benefit of early intervention outweighs the risk. A single-center analysis by Gertler et al. found no significant increase in adverse events following urgent repair and found that it was warranted, given the increased risk of recurrent stroke in neurologically unstable patients.28 Another single-center analysis similarly found no significant increase in stroke/death based on the time from intervention to procedure.29 Despite these single-center results showing no difference our analysis found that the perioperative stroke/death rate in symptomatic patients was 3.2% for urgent interventions and 10% for emergent interventions, compared to just 1.2% for elective procedures. Similar to our findings, the Swedvasc study also found a fourfold increase in risk with a stroke/death rate of 11% for interventions within 48 hours. The rate was even higher in subgroup analysis of only patients with crescendo TIA.8 The Carotid Alarm study similarly demonstrated a stroke/death rate of 8% in patients who underwent CEA within 48 hours compared to 2.9% for those who underwent CEA between 3 and 14 days after symptoms.30 Similarly, using the VQI, Solomon et al. showed that in patients with stroke, intervention within 48 hours was associated with increased odds of stroke/death, although this varied based on the severity of the stroke. Citing the study by Ois as well as the results of the Swedvasc study, Naylor et al. argued that the elevated procedural risk was justified in some cases given the high risk for recurrence. However, most of the estimates of recurrence risk are lower than the risk of stroke/death patients following urgent or emergent surgery.
The current SVS guidelines suggest that intervention should not be undertaken in patients with disabling strokes, with a modified Rankin score of ≥3.31 The guidelines also suggest that revascularization is not appropriate in patients with complete occlusion of the ipsilateral internal carotid.7 We found that 33% of emergent procedures and 13% of urgent procedures were done in patients with a Rankin score of ≥3. Additionally, 32% of emergent procedures were done in patients with complete occlusion. A sensitivity analysis removing patients with complete occlusion did result in a lower stroke/death rate, however in emergent cases it still exceeded guideline recommendations of less than 6% in symptomatic patients or the 4% threshold recommended for in hospital stroke/death.32,33 These data further underscores the risk associated with revascularization in patients with disabling strokes or occlusion and further supports adherence to SVS guidelines.
The fact that there were a large number of asymptomatic patients in our analysis is also concerning, as there are few indications for urgent intervention in this population. While there are no prior analyses of outcomes based on urgency in asymptomatic patients, O’Donnell et al. found that cases done on weekends, for both asymptomatic and symptomatic patients, were associated with higher odds of stroke/death relative to cases done on weekdays.34 A similar analysis by procedure type also found that asymptomatic CEA and tfCAS patients had higher complications and mortality when cases were done on the weekend. While the weekend effect may explain some of the worsening outcomes in asymptomatic patients, as 15% of emergent cases occurred on the weekend, there are likely other factors contributing as well. It is possible that some of the remaining asymptomatic patients were treated later in the day, which could also contribute to worse outcomes, although there is some disagreement as to the extent of this risk in the literature.35,36 Need for an emergent CABG with concomitant CEA could also lead to urgent or emergent CEA in asymptomatic patients. Although uncommon, emergent CABG with CEA in a neurologically asymptomatic patient was associated with a stroke/death rate of 30%. This small subgroup did not alter our overall results, although they did likely lead to worse outcomes in the sub analysis of asymptomatic patients undergoing CEA. There also could be a biological explanation, such as unstable plaque morphology which is not captured in the VQI.
Our data also demonstrate that outcomes for urgent and emergent cases are worse across procedure types. Both CEA and tfCAS demonstrated worse outcomes for both urgent and emergent cases in asymptomatic and symptomatic patients. TCAR was associated with higher stroke/death for urgent procedures, and symptomatic emergent procedures, but this did not reach significance in asymptomatic emergent procedures. It should be noted that there were fewer emergent TCARs, making it likely that this subgroup was underpowered to detect differences, not that patient undergoing emergent TCAR fare better. Solomon et al. similarly found that patients undergoing intervention within 48 hours had high rates of stroke/death overall, that this was most pronounced in tfCAS patients, and that CEA was the safest option within this period.37,38 We found that CEA and TCAR were associated with lower risk of stroke/death in symptomatic patients for both urgent and emergent procedures relative to tfCAS. However, CEA performed slightly better in urgent procedures and TCAR performed slightly better in emergent ones. CEA had better outcomes for urgent procedures in asymptomatic patients, while TCAR performed better in emergent procedures, although it did not reach significance.
This study has several limitations due to its retrospective design. As we do not have access to patients managed medically for comparison, we cannot directly assess the risk of recurrent stroke without intervention in this population. Clinical registry data can also be subject to incomplete or missing variables and errors in data entry, although the VQI has robust auditing and quality control mechanisms.39 It is possible that at least some of the patients documented as asymptomatic who underwent urgent or emergent repairs were symptomatic and had their data entered incorrectly. Given the differences in outcomes between asymptomatic and symptomatic patients, incorrect data does not fully explain why there are so many asymptomatic urgent or emergent cases. Additionally, VQI does not capture data on the evolution of a stroke or crescendo TIA, which are two leading indications for urgent repair making it impossible to determine whether a given procedure met guidelines or not. It also does not capture plaque morphology, which could help explain some of the asymptomatic urgent and emergent cases. Capture of long-term outcomes is also limited, limiting analysis of outcomes beyond the perioperative period.
CONCLUSION
Urgent or emergent carotid revascularization was associated with higher odds of all perioperative outcomes. Given the higher risk of urgent or emergent surgery and the relatively few indications for expedited revascularization, careful consideration should be given to the risk of the procedure compared to the risk of recurrent symptoms within the first 48 hours following symptoms. Additionally, while CEA and TCAR perform similarly in urgent cases, TCAR may be the safest option for cases within 6 hours of presentation.
Supplementary Material
ARTICLE HIGHLIGHTS.
Type of Research:
Multicenter retrospective analysis of prospectively collected Vascular Quality Initiative data.
Key Findings:
In this observational study, we analyzed 224,509 carotid revascularizations from 2011-2024. Patients were stratified based on urgency of the procedure and preoperative symptom status. We found that urgent and emergent procedures were associated with significantly higher odds of stroke/death compared to elective procedures.
Take home Message:
Both urgent and emergent carotid revascularization were associated with significantly higher odds of stroke/death regardless of procedure choice. The risk of surgery during this period should be weighed carefully against the risk of recurrent stroke and undertaken only in carefully selected patients.
Table of Contents Summary:
Despite relatively few indications for carotid revascularization within the first 48 hours following symptoms, 32,264 (14%) urgent, and 3,327 (1%) emergent cases were recorded in the VQI. Both urgent and emergent cases were associated with significantly higher odds of stroke/death. The risk of surgery during this period should be weighed carefully against the risk of recurrent stroke and undertaken only in carefully selected patients.
ACKNOWLEDGEMENTS
This work was conducted with support from Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UM1TR004408) and financial contributions from Harvard University and its affiliated academic healthcare centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University, and its affiliated academic healthcare centers, or the National Institutes of Health.
Funding:
EC was supported by the Harvard-Longwood Research Training in Vascular Surgery NIH T32 Grant 5T32HL007734-30.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Presentation: These data were presented as a podium presentation at SCVS, March 2025, Austin, TX.
Conflicts of Interest: The authors have no competing interests.
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