IF05 - Contemporary Trends and Age-Based Outcomes of Carotid Revascularization for Asymptomatic Carotid Artery Stenosis

Objectives: Revascularization for asymptomatic carotid artery stenosis (aCAS) remains controversial. The aim of this study is to describe contemporary trends and age-based outcomes of carotid revascularization for aCAS in the Vascular Quality Initiative.

Methods: Asymptomatic patients undergoing carotid endarterectomy (CEA), transCarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TfCAS) in the VQI database between 2016-2022 were queried. For each revascularization technique, baseline characteristics, procedural variables, and in-hospital and 1-year outcomes (stroke, death, myocardial infarction (MI), stroke/death) were compared among 3 age groups (<=70, 71-79 and >= 80 years) using univariable and multivariable analysis.

Results: 112,678 patients with aCAS were included in the analysis (CEA 66.7%, TCAR 21.6%, TFCAS 11.8%), representing 70% of all carotid revascularization performed between 2016 and 2022. During the study period, there has been a decrease in the percentage of procedures performed for aCAS (Figure 1). Patients >= 80 years of age constituted 18% of asymptomatic patients undergoing revascularization. Older patients had more medical comorbidities but were less likely to be on antiplatelets and statins preoperatively compared to younger age groups (90% vs. 92% and 84.6% vs. 87%, respectively,P < 0.001). For CEA, patients>= 80 years had higher rates of in-hospital mortality [0.4% vs 0.2%, aOR (95%CI):1.70 (1.08-2.67), P=0.02], stroke/death [1.3% vs.1.1%, aOR (95%CI):1.26 (1.02-1.56),P=0.03] and 1-year stroke/death [6.2% vs.1.4%, aHR (95%CI):1.79 (1.57-2.04), P< 0.001] compared to asymptomatic patients<= 70 years (Table 1). For TCAR, in-hospital outcomes were not significantly different between the 3 age groups; however, patients>= 80 years had higher 1-year mortality [5.7% vs. 3.9%, aHR(95%CI): 1.59 (1.27-1.99),P < 0.001] and stroke/death [5.6% vs. 4.4%, aHR(95%CI):1.36 (1.05-1.76), P=0.02] compared to those <= 70 years of age. For TFCAS, age>= 80 years was significantly associated with increased in-hospital stroke [2.5% vs.1.4%, aOR(95%CI):1.69 (1.15-2.48), P=0.01], death [1.3% vs. 0.5%, aOR(95%CI):2.19 (1.22-3.93), P=0.01], stroke/death (3.5% vs 1.5%, OR(95%CI): 1.89 (1.33-2.68), P< 0.001) as well as 1-year mortality (10.5% vs. 4.3%, aHR (95%CI): 2.44 (1.93-3.10)] and stroke/death [ 9.6% vs 4.6%, aHR (95%CI) 2.03 (1.58-2.62), P< 0.001] compared to age<=70 years.

Conclusions: The majority of carotid revascularization in the U.S. is performed for aCAS, with continued use of these procedures for patients older than 80 years. Asymptomatic patients older than 80 years have increased rates in-hospital mortality and stroke/death extending up to 1-year of follow up. These findings call for careful patient selection, medical optimization, and avoidance of transfemoral carotid artery stenting when considering revascularization in patients with aCAS.