LAUSR

OBJECTIVE Carotid endarterectomy (CEA) with concomitant distal endovascular intervention (CEA+D) is infrequently necessary, and often a salvage maneuver when complications occur during CEA. This study aims to determine if there are preoperative risk factors associated with CEA requiring CEA+D and evaluate outcomes compared to isolated CEA. METHODS The Vascular Quality Initiative (VQI) CEA registry was utilized to identify patients undergoing CEA and CEA+D for asymptomatic or symptomatic carotid stenosis from 2013-2019. Data regarding distal intervention includes whether angioplasty or stent of the distal ICA and/or bifurcation was required, but information regarding indication or if intervention was planned is not included. X2 and ANOVA were used, to evaluate categorical and continuous perioperative variables. Variables with p<.20 on univariate analysis were placed in multivariable analysis to assess for preoperative predictors of need for CEA+D and association with perioperative stroke. RESULTS From 2013-19, 327 CEA+D were identified and compared to 105,192 isolated CEA. CEA+D patients were more likely to have prior ipsilateral CEA (CEA: 1.8%, CEA+D: 4.9%; p<.01) and contralateral ICA occlusion (CEA: 4.6%, CEA+D: 11.0%; p<.01), but were less likely to have ipsilateral stenosis ≥70% (CEA: 88.3%, CEA+D: 80.6%; p<.01). Preop factors associated with need for CEA+D on multivariable analysis included prior peripheral vascular intervention, ASA class ≥4, contralateral ICA occlusion, low volume surgeon, and prior ipsilateral CEA. CEA+D was associated with significantly increased rates of stroke in both asymptomatic (CEA+D: 3.9%, CEA: 0.9%; p<.01) and symptomatic (CEA+D: 9.4%, CEA:1.9%; p<.01) patients. CEA+D was associated with decreased rates of 30-day survival in both asymptomatic (CEA+D: 98.3%, CEA: 99.4%; p=.02) and symptomatic (CEA+D: 94.8%, CEA: 99.1%; p<.01) cohorts. On multivariable analysis, CEA+D remained significantly associated with stroke (OR: 3.17, 95%CI: 1.80-5.60; p<.01). Other factors significantly associated with perioperative stroke included procedure length >135 minutes, diabetes, hypertension, shunt for indication, symptomatic status, prior ipsilateral CEA, contralateral ICA occlusion, urgent/emergent procedure, IV medications for hemodynamic instability, and re-exploration at initial operation. CONCLUSION While markers of more significant cardiovascular disease burden were associated with use of CEA+D, their power to predict CEA+D use is limited. In cases where CEA+D is employed, CEA+D is associated with significantly higher rates of perioperative stroke and mortality in comparison to isolated CEA in both asymptomatic and symptomatic patients, which can be useful framing expected outcomes after these procedures.