Addition of Common Carotid Intervention Increases the Risk of Stroke and Death after Carotid Artery Stenting for Asymptomatic Patients

BACKGROUND A recent review of VSGNE data suggested that simultaneous endovascular treatment of tandem carotid lesions (TCAL: common carotid artery (CCA)+internal carotid artery (ICA)) is associated with a four-fold increase in perioperative neurological events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous TCAL stenting in cohorts stratified by symptom status. METHODS VQI data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis<50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative stroke and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with TCAL forced into the models. RESULTS There were 18,886 carotid arteries stented (18,441 patients); 18,077 (96%) with isolated carotid artery lesions (ICAL), 809 (4%) with TCAL. Mean age was 70.0±9.7. Symptomatic lesions were present in 58.9% of cases (ICAL: 59.1% vs TCAL: 52.5%; p<0.001). More TCAL arteries had a prior CEA (38.3% vs. 23.8%; p<0.001). TCAL had a higher perioperative stroke/death (3.4% vs 1.8%; p=0.026) for asymptomatic lesions, but not symptomatic lesions (4.5% vs 3.7%; p=0.41). TCAL were independently associated with stroke/death in asymptomatic patients (OR 1.85; 95% CI: 1.03-3.33; p=0.039) but not symptomatic patients (OR 1.22; 95% CI: 0.76-1.97; p=0.42). CONCLUSION Addition of endovascular treatment of CCA lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of TCAL is not associated with an increased risk of stroke/death for symptomatic lesions.