Contralateral carotid occlusion (CCO) may be a predictor of increased risk among patients undergoing carotid endarterectomy (CEA) but not among those undergoing carotid artery stenting (CAS), according to a study published Feb. 15 in the Journal of the American College of Cardiology.

Anna K. Krawisz, MD, et al., used data from ACC's PVI Registry, operated in collaboration with the Society for Vascular Surgery Vascular Quality Initiative, to determine the clinical impact of CCO among patients undergoing CEA and CAS. The researchers looked patients who underwent carotid revascularization from 2007 to 2019. The study's primary exposure was the presence of CCO, and the primary endpoint was a composite of in-hospital death, stroke and myocardial infarction (MI).

In a total of 58,423 patients undergoing carotid revascularization, 4,624 (7.9%) had a CCO. Of these, 1,439 (31.1%) received CEA, while 3,185 (68.9%) received CAS. Among patients with CCO, the average age was 69.5 years, 32.6% were women, 92.8% were Caucasian, 51.7% had a previous transient ischemic attack or stroke, and 45.4% presented with symptomatic disease.

Over the study period, prevalence of CCO in patients undergoing carotid revascularization decreased by 41.7%, although CAS remained the primary procedure. In unadjusted analyses, the primary outcome was higher in patients with CCO undergoing CEA (3.6%) vs. CAS (2.1%). After adjustment, CCO was associated with a 71% increased risk of an adverse outcome following CEA (95% confidence interval [CI]: 1.27-2.30; p<0.001), compared with no increase following CAS (adjusted odds ratio: 0.94; 95% CI: 0.72-1.22; p=0.64).

According to the researchers, CCO "remains an important predictor of risk of in-hospital death, MI, or stroke among patients undergoing CEA, but not among those undergoing CAS." The study's findings "support the continued use of CCO to guide the selection of carotid revascularization strategies among patients with carotid artery disease," they conclude.

The study "adds to the debate on use of CEA and CAS in patients with CCO," Gregory L. Moneta, MD, writes in an accompanying editorial comment. However, he adds that the "data does not provide readers with answers to the most important questions regarding the management of patients with CCO: who is best managed medically, under what circumstances is CEA or CAS best, and what are long-term outcomes?"

Clinical Topics: Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Heart Failure and Cardiac Biomarkers, Interventions and Vascular Medicine

Keywords: Carcinoembryonic Antigen, Endarterectomy, Carotid, Ischemic Attack, Transient, Hospital Mortality, Stents, Stroke, Carotid Artery Diseases, Myocardial Infarction, Registries, National Cardiovascular Data Registries, Carotid Arteries, PVI Registry

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