Outcomes of primary and secondary carotid artery stenting

Abstract

Background and Purpose-Little is known of the excess risk attributable to secondary carotid angioplasty and stenting (CAS). This study evaluates outcomes of redo-CAS and CAS after prior ipsilateral carotid endarterectomy (CASAPICEA) relative to primary-CAS. Methods-We studied all patients in the Vascular Quality Initiative, who underwent primary-CAS, CASAPICEA, or redo-CAS (2003-2016). Kaplan-Meier, multivariable logistic and Cox regression analyses were used to evaluate outcomes within 30 days and up to 1 year and identify their predictors. Results-There were 11 742 CAS procedures performed: 8519 (72%) primary-, 2645 (23%) CASAPICEA, and 578 (5%) redo-CAS. Comparing primary-CAS versus CASAPICEA versus redo-CAS, 30-day stroke/death was 2.5% versus 2.0% versus 1.3% for asymptomatic patients (P=0.23) and 5.2% versus 2.6% versus 5.0% for symptomatic patients (P=0.003). CASAPICEA was associated with significantly lower 30-day stroke/death (odds ratio: 0.60; 95% confidence interval: 0.37-0.98; P=0.04) compared with primary-CAS among symptomatic patients. The odds of bradycardia were lower following CASAPICEA (odds ratio: 0.32; 95% confidence interval: 0.26-0.39; P<0.001) and redo-CAS (odds ratio: 0.55; 95% confidence interval: 0.39-0.78; P=0.001) compared with primary-CAS. Similarly, the odds of hypotension were significantly lower in both groups compared with primary-CAS (CASAPICEA: 0.41 [0.35-0.48], P<0.001; redo-CAS: 0.66 [0.50-0.86] P=0.003). There were no significant differences in the hazards of stroke/death at 1 year for CASAPICEA and redo-CAS compared with primary-CAS. Conclusions-CASAPICEA is associated with significantly lower odds of periprocedural stroke/death compared with primary-CAS among symptomatic patients. CASAPICEA and redo-CAS are associated with significantly lower odds of periprocedural hypotension and bradycardia but higher odds of hypertension compared with primary-CAS.