Carotid artery revascularization in patients with contralateral carotid artery occlusion: Stent or endarterectomy?

Abstract

Background The Centers for Medicare and Medicaid Services (CMS) considers that contralateral carotid artery occlusion puts the patients at high risk for carotid endarterectomy (CEA) and agrees to reimburse for carotid artery stenting (CAS) in these patients. However, there is a paucity of evidence that support the superiority of CAS compared with CEA in patients with contralateral carotid occlusion. Methods All patients who underwent CEA or CAS with contralateral carotid artery occlusion were identified in the Vascular Quality Initiative (VQI) registry between 2005 and 2016. Outcomes examined were stroke, death, and myocardial infarction at 30 days and stroke and death at 2 years stratified by ipsilateral symptomatic status. Multivariable logistic regression analysis was implemented to estimate the odds ratios (ORs) of 30-day outcomes controlling for potential confounders. Life tables, robust Cox proportional hazard clustered by centers, and log-rank tests were implemented to estimate the hazard ratios (HRs) for long-term events. Results Overall, 4326 patients had contralateral carotid artery occlusion (CEA: 3274 [75.7%] vs CAS: 1052 [24.3%]). Patients' demographic and comorbidities were generally similar in both groups, except for race, in which nonwhite patients were more likely to have CAS (9.5% vs 7.6%; P =.048). History of stroke was twice as much prevalent in patients undergoing CEA (56.4% vs 24.0%; P