Michael neilson MD 1 Mahmoud malas MD MHS 2 Grace wang MD 3 Vikram Kashyap MD 4 Raghu motaganahalli MBBS 4 Marc Schermerhorn MD 5 Jack cronenwett MD 6 Jens Eldrup ID: 794396
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Slide1
The Effect of Carotid Calcification on Outcomes of Transfemoral and Transcarotid Artery Stenting in the VQI
Michael neilson, MD1Mahmoud malas, MD, MHS2Grace wang, MD3Vikram Kashyap, MD4Raghu motaganahalli, MBBS4Marc Schermerhorn, MD5Jack cronenwett, MD6Jens Eldrup-Jorgensen, MD1Brian Nolan, MD1
1-Maine Medical Center, 2-UCSD, 3-UPENN, 4 Indiana University, 5- Beth Israel
Deconess
, 6-Dartmouth
Slide2No disclosures
2
Slide3Carotid artery calcification has been previously reported as a risk factor for post-operative neurologic outcomes following transfemoral carotid stenting (TF-CAS).1
Transcarotid Artery Revascularization (TCAR) has been shown to be safe and effective treatment of carotid stenosis, especially in otherwise high risk individuals.21.AbuRahma AF, DerDerian T, Hairi N et al. Anatomic and technical predictors of perioperative clinical outcomes after carotid artery stenting. J Vasc Surg. 2017;66(2): 423-432.2. Wang Sk, Fajardo A, Sawchuk AP, et al. Outcomes associated with Transcarotid artery revascularization-centered protocol in high risk carotid revascularization using the ENROUE neuroprotection system. J Vasc Surg. 2019;69(3):807-813.Introduction
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1
Slide4Carotid Calcification in VQI
Reported since 2016Subjective report of degree of calcification of carotid lesionReported as degree of circumferential calcification<25%, 25-50%, 51-99%, 100%
Slide5Compare outcomes of TF-CAS and TCAR stratified by degree of circumferential carotid calcification in the VQI
Objective
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Slide6Retrospective cohort study of all CAS in the VQI, 2016-2019Analyzed by degree of calcification<25%, 25-50%, 51-99%, 100%
Primary endpointStroke occurring during index hospitalizationSecondary EndpointsMajor adverse cardiac events (MACE), hemodynamic suppressionMultivariate logistic regression analysis to predict carotid calcificationMethods
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Slide7Results
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Carotid Stenting in VQI, 2016-2019
N=4834
39%
(n=1890)
61%(n=2944)
Slide8Degree of Calicification
<=25% (n=2400)
26-50% (n=885)
51-99% (n=1,361)
100% (n=188)
p-value
Age
687172
73
0.022
Female
35%
34%
37%
43%
0.050
Symptomatic (stroke or TIA)
61%
64%
60%
61%
0.409
Primary lesion
70%
86%
87%
88%0.001Hypertension84%88%91%86%0.001MI or agina25%26%30%23%0.006Prior PCI or CABG32%37%40%37%0.001Prior dysrhythmia16%20%24%24%0.001CHF14%19%20%20%0.001Current smoker38%38%37%39%0.971COPD23%28%29%27%0.001ESRD1%2%2%1%0.162Current ASA83%87%86%85%0.006Current P2Y73%78%80%71%0.001Current statin78%83%87%85%0.001Triple therapy58%63%66%63%0.001Non-white race13%10%10%9%0.015
Patient Demographics
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Slide9Primary Outcomes
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TCAR p= 0.943
TF-CAS p< 0.001
Slide10Secondary Outcomes
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TF-CAS p< 0.001
TCAR p < 0.001
** Hypotension and/or bradycardia
Slide11Secondary Outcomes
TF-CAS p = 0.21TCAR p = 0.02
Slide12ORp value95% CIAge > 80
2.22
0.001
1.80
2.74
Ae 70 to 79
1.69
0.0011.412.03
Age 60 to 69
1.42
0.001
1.178
1.714
Atherosclerotic lesion
2.67
0.001
2.28
3.10
COPD
1.34
0.001
1.17
1.53
CHF
1.27
0.004
1.081.51HTN1.330.0021.121.61Prior CABG or PCI1.130.0481.011.30Diabetes1.170.0151.031.33Non white race0.740.0020.6140.90Predictors of Carotid Calcification
Slide13Self reported degree of calcification within VQI, not adjudicatedRetrospective in nature, can only show association, not causation
Limitations
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Slide14Increasing degree of calcification is associated with increasing rates of post-operative CVA following TF-CAS This is not seen after TCAR
Rate of hemodynamic suppression increases with increasing calcification following both procedures, particularly following TCAR, but this needs further investigationMultiple risk factors for increasing degree of carotid calcificationSummary
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Slide15TCAR may be an acceptable alternative even in patients with extensive calcification, though with cautionCan predict possibility of carotid calcification which may effect treatment type and pre-operative imaging
Conclusions
Slide1616
Thank You
Slide17Transfemoral
Degree of Calicification
<=25% (n=1568)
26-50% (n=512)
51-99% (n=757)
100% (n=107)
p-value
Postop Neuro event
2.2%2.9%4.4%
9.3%
0.001
Postop Hypotension
12%
17%
16%
16%
0.015
Bradycardia
11%
15%
15%
12%
0.034
HD suppression
20%
26%
25%
23%0.010Cardiac event2.8%2.9%2.1%5.6%0.21TCARDegree of Calicification <=25% (n=832)26-50% (n=373)51-99% (n=604)100% (n=81)p-valuePostop neuro event2.3%2.1%2.2%1.2%0.943Postop hypotension12%16%16%26%0.004Bradycardia10%10%13%15%0.139HD suppression21%23%26%39%0.001Postop cardiac event2.4%0.3%2.6%1.2%0.02Outcomes17
Slide18Results
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P=0.001
P=0.001
P=0.04
P=0.253
Slide19Degree of Calicification
<=25% (n=2400)
26-50% (n=885)
51-99% (n=1,361)
100% (n=188)
Pre and
postdilate
30%
28%24%25%Pre dilate only
6%
5%
7%
5%
Post dilate
65%
68%
69%
70%
Results: Procedural Details
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P=.0011