Age-and-Outcomes Analysis of the VQI Supports TCAR in Elderly Patients

 

June 12, 2019—Hanaa Dakour-Aridi, MD, revealed findings from a study composed of patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) that compared the association between age and outcomes after transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), and carotid endarterectomy (CEA). Presented at the SVS Vascular Annual Meeting held June 12–15 in National Harbor, Maryland, the study's text and tables by Dakour-Aridi et al are available online in SVS's Journal of Vascular Surgery (2019;69:e60–e61).

TCAR, which combines surgical principles of neuroprotection with endovascular techniques to treat blockages in the carotid artery while avoiding passing through the aortic arch, is performed with the Enroute transcarotid stent (Silk Road Medical) in conjunction with the Enroute transcarotid neuroprotection system (NPS). The NPS is used to directly access the common carotid artery and initiate high-rate temporary blood flow reversal to protect the brain from stroke while delivering and implanting the Enroute stent.

The analysis demonstrated advantages of TCAR in elderly patients, with significant decreases in adverse outcomes in patients ≥ 77 years old, independent of symptomatic status and other medical comorbidities. TCAR was shown to be a relatively safe procedure regardless of the patient's age, with no significant differences between TCAR and CEA across the age spectrum. The findings suggest that TCAR should be considered in elderly patients who are at high surgical risk, concluded the investigators.

The background of the study is that the increased prevalence of severe aortic arch atherosclerosis in elderly patients has been correlated with increased embolic lesions during TFCAS. Previous data showed a higher relative risk of stroke postprocedure at older ages, whereas the risk for stroke after CEA remained relatively constant across the entire age spectrum. TFCAS is now contraindicated in octogenarians by most experienced operators based on this body of evidence, noted the investigators.

In the study, all patients who underwent carotid procedures in the VQI database between 2015 and November 2018 were divided into three different age groups (≤ 70, 71–79, and ≥ 80 years) based on the location of knots in the restricted cubic spline models where significant changes in the odds of in-hospital stroke/death occurred.

In-hospital outcomes after TCAR (n = 3,152 at 174 centers) versus TFCAS (n = 10,381 at 269 centers) and TCAR versus CEA (61,650 at 347 centers) were compared in each age group by introducing an interaction term between treatment type and age in the logistic regression analysis, after adjusting for symptomatic status, gender, coronary artery disease, congestive heart failure, diabetes, hypertension, chronic kidney disease, previous ipsilateral CEA, and elective status.

The investigators reported that the absolute and adjusted in-hospital outcomes after TCAR did not change across the different age groups.

The study demonstrated similar outcomes in the following comparisons:

  • Rates of in-hospital stroke/death after TCAR were 1.4% (≤ 70 years), 1.9% (71–79 years), and 1.5% (≥ 80 years) (P = .55).
  • For TCAR versus CEA, there were no significant differences in outcomes across different age groups, and no interaction was noted between treatment and age.
  • For TCAR versus TFCAS, there were no differences in patients < 80 years of age.

However, in patients ≥ 80 years of age, TCAR compared with TFCAS showed:

  • 72% reduction in stroke risk (4.7% vs 1%; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12–0.65; P < .01)
  • 65% reduction in risk of stroke/death (4.6% vs 1.5%; OR, 0.35; 95% CI, 0.2–0.62; P < .001)
  • 76% reduction in the risk of stroke/death/myocardial infarction (5.3% vs 2.5%; OR, 0.24; 95% CI, 0.12–0.47; P < .001)
  • The odds of stroke/death after TFCAS doubled at 77 years (OR, 2.1; 95% CI, 1.4–3; P < .01) and tripled at 90 years (OR, 3; 95% CI; 1.65–5; P < .01; Pinteraction = .08).

Previously, data from the VQI showed that TCAR compared with CEA resulted in similar rates of in-hospital stroke and death with shorter operating room time and fewer cranial nerve injuries. Marc Schermerhorn, MD, presented these findings at the 45th annual VEITHsymposium held November 13–17, 2018, in New York, New York.

 

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