VQI Data Show Improved Outcomes of Transfemoral CAS With Better Stratification of Preprocedural Symptoms

June 24, 2021—The Society for Vascular Surgery (SVS) announced the publication of an article suggesting that further stratification according to preprocedural symptoms in patients undergoing transfemoral carotid artery stenting (TFCAS) improves the preoperative risk assessment. The findings from a review of the SVS Vascular Quality Initiative (VQI) data were published by Yoel Solomon, BS, et al in Journal of Vascular Surgery (2021;73:2021-2029).

The SVS announcement stated that the purpose of the study was to provide and update the contemporary perioperative outcomes after TFCAS stratified by the specific preprocedural symptoms in a real-world setting of a large clinical registry.

“Most previous studies investigating outcomes after carotid revascularization stratified the patient population as either symptomatic or asymptomatic; they did not specify the degree of presenting neurologic injury,” noted principal author Marc L. Schermerhorn, MD, in the SVS press release.

As summarized by SVS, the investigators studied 9,807 patients who had undergone TFCAS from 2016 to 2020 and are in the VQI database. They stratified patients according to their preprocedural symptom status as asymptomatic, formerly symptomatic, or recently symptomatic. The symptoms included stroke, hemispheric transient ischemic attack (TIA), and ocular TIA.

The cohort (average age, 70 years [interquartile range, 64-77]) had the following preprocedural symptom classifications: recent (< 180 d) stroke, n = 2,650 (27%); recent hemispheric TIA, n = 842 (9%); recent ocular TIA, n = 360 (4%); formerly (> 180 d) symptomatic, n = 795 (8%); and asymptomatic, n = 5,160 (53%).

The investigators observed the perioperative stroke/death rates varying according to symptom status: recent (< 180 d) stroke, 5.5%; recent hemispheric TIA, 2.4%; recent ocular TIA, 2.8%; formerly (> 180 d) symptomatic, 3.5%; and asymptomatic, 1.4%.

After risk adjustment, the odds ratio for stroke/death were observed to be: recent stroke versus TIA, 2.6 (P < .001); recent stroke versus asymptomatic, 4.1 (P < .001); and asymptomatic versus formerly symptomatic, 0.4 (P < .001).

Given that little error is allowed in the treatment of carotid disease, both symptomatic and asymptomatic, these findings highlight the importance of better stratifying patients preoperatively with regard to symptom status, noted SVS.

Dr. Schermerhorn, who is with the Beth Israel Deaconess Medical Center in Boston, Massachusetts, commented further in the SVS announcement, “This study supports the practice of using specific preprocedural symptom status in the preoperative risk assessment of patients undergoing TFCAS. Of particular interest is that differentiating between formerly symptomatic (symptoms dating > 180 days before intervention) and asymptomatic patients may allow for greater accuracy in outcomes reporting in future studies.”