LAUSR

BACKGROUND The outcomes of carotid revascularization in patients with contralateral carotid artery occlusion (CCO) are controversial. CCO has been defined by CMS as a high-risk criterion and used as an indication for transfermoral carotid artery stenting (TFCAS). With the promising outcomes associated with TransCarotid artery revascularization (TCAR), we aim to study the perioperative outcomes of TCAR in patients with CCO, and to assess the feasibility of TCAR in these high-risk patients. METHODS All patients in the VQI dataset who underwent TCAR with flow reversal between September 2016 and May 2019 were included. Patients with trauma, dissection or more than 2 treated lesions were excluded. Univariable and multivariable logistic analysis were used to compare the primary outcome of in-hospital stroke or death after TCAR in patients with CCO and those without CCO (patent and <99% stenosis). Secondary outcomes included intraoperative neurological changes, and the individual outcomes of in-hospital stroke, death and myocardial infarction (MI) as well as 30-day mortality. RESULTS A total of 5,485 TCAR cases were included, of which 593 (10.8%) had CCO. In patients with CCO, mean flow reversal time was shorter (10.1 ± 6.7 min vs. 11.1± 7.8 min, P<.01) while intraoperative neurologic changes occurred in 1% of these patients compared with 0.7% of those with patent contralateral carotid arteries (p=.43). On univariable analysis, no significant difference in in-hospital stroke or death was shown between patients with and without CCO (1.7% vs. 1.5%, p=.65). Similarly, no significant differences were noted between the two groups in terms of in-hospital death (0.7% vs. 0.4%, p=.27), stroke (1.7% vs. 1.2%, p=.32) and stroke/death/MI (2.2% vs. 1.8%, p=.53), as well as 30-day mortality (0.8% vs. 0.6%, p=.55). The results remained statistically non-significant after adjusting for baseline differences between the two groups; the adjusted odds ratio of in-hospital stroke/death in patients with CCO compared to those with patent contralateral carotid arteries was not significant [OR (95%CI):1.39 (0.65-3.0), P=.40]. In symptomatic patients presenting with prior stroke, CCO was associated with significantly higher odds of stroke or death [OR (95%CI): 4.63 (1.39-15.4), P=.01] compared to no CCO. On the other hand, in asymptomatic patients, no significant difference in outcomes was observed between the two groups. CONCLUSION In this analysis, TCAR seems to be a safe in patients with CCO. Caution should be taken in symptomatic patients with CCO and a history of prior stroke as they might have worse outcomes compared to patients with patent contralateral carotid arteries. Studies with larger sample size and longer follow-up are needed to assess the perioperative and long-term outcomes of TCAR in patients with CCO in comparison to other procedures.