Higher long-term mortality in patients with positive preoperative stress test undergoing elective carotid revascularization with carotid endarterectomy compared to transfemoral carotid artery stenting or transcarotid revascularization

Abstract

Objective: This study compared outcomes in patients with and without preoperative stress testing undergoing carotid revascularization including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid revascularization (TCAR).

Methods: Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database who underwent elective carotid revascularization from 2016 to 2020 were included. Patients were analyzed by group based on whether they underwent cardiac stress testing within 2 years preceding revascularization without subsequent coronary intervention. Subset analysis was performed comparing outcomes between those with negative and positive results (evidence of ischemia or myocardial infarction [MI]). Outcomes of interest were postoperative MI/neurological events, 90-day readmission rates, and long-term mortality.

Results: We analyzed 18,364 patients (78.8% CEA, 9.3% TF-CAS, and 11.9% TCAR). Of these, 35.8% underwent preoperative stress testing (37.4% of CEA patients, 27.5% of TF-CAS patients, and 31.9% of TCAR patients). Although comorbidities were significantly higher among patients undergoing CEA with a preoperative stress test compared with those without stress testing, the overall prevalence of comorbidities was higher among patients undergoing TF-CAS or TCAR, irrespective of preoperative stress test status. Compared with patients with a negative stress test, patients with a positive stress test undergoing any form of carotid revascularization had a significant increase in 90-day readmission rates (CEA 19.6% vs 15.8% [P = .003]; CAS 33.3% vs 18.6% [P < .001]; TCAR 25% vs 17.5% [P = .04]). No group demonstrated a difference in the incidence of in-hospital postoperative neurological events or congestive heart failure, but those undergoing CEA (but not CAS or TCAR) experienced a significant increase in-hospital postoperative MI (1.7% vs 0.6%; P < .001). In 3-year follow-up, those with a positive compared with negative stress test were more likely to undergo coronary artery bypass graft/percutaneous coronary intervention in the CEA (adjusted hazard ratio [HR], 1.87 [95% confidence interval (CI), 1.42-2.27]; P < .0001) and CAS groups (adjusted HR, 3.89 [95% CI, 1.77-8.57]; P < .01), but not the TCAR cohort. Notably, those undergoing CEA with a positive compared with negative stress test, but not CAS or TCAR, exhibited a 28% increase in mortality (adjusted HR, 1.28 [95% CI, 1.03-1.58]; P = .03) at 3 years. Conversely, those patients with a negative stress test compared with no stress test undergoing CEA experienced a 14% decrease in mortality at 3 years (adjusted HR, 0.86 [95% CI, 0.76-0.98]; P = .02); this mortality difference was not observed in similar stress test cohorts undergoing TF-CAS or TCAR.

Conclusions: Our study highlights that a positive stress test in appropriately selected, asymptomatic patients undergoing elective carotid revascularization can predict select perioperative and long-term cardiovascular outcomes. However, given the high follow-up mortality associated with those undergoing CEA for elective carotid revascularization, our findings call into question whether these patients should be offered optimal medical management and/or stenting preferentially.

Keywords: Carotid endarterectomy; Carotid revascularization; Preoperative cardiac testing; Stress testing.