Simultaneous Treatment of Tandem Carotid Artery Lesions Risky for Asymptomatic Patients

No guidelines exist for the treatment of tandem carotid artery lesions (TCAL)—the internal carotid artery and common carotid artery in series. This disease pattern is difficult to manage partly because of the inability to determine which lesion is the embolic source in symptomatic patients.

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The general practice for symptomatic patients is to treat both lesions if both have stenosis >70% or there are concerning plaque characteristics. However, Massachusetts General Hospital researchers recently reported in the Journal of Vascular Surgery that among 1,950 patients, simultaneous endovascular treatment of TCAL was associated with threefold increased risk of perioperative stroke or death compared with the treatment of isolated lesions.

Building on that research, Charles DeCarlo, MD, surgical resident, and Mark F. Conrad, MD, MMSc, director of Clinical Research in the Division of Vascular and Endovascular Surgery at Massachusetts General Hospital, and colleagues studied a larger, international cohort. In another paper published in the Journal of Vascular Surgery, they say symptom status modifies the risk of stroke/death and should be considered when making management decisions.

Study Methods

The analysis made use of data from the Vascular Quality Initiative, a prospectively maintained registry that collects information on common vascular procedures performed at over 500 institutions in the U.S. and Canada. The researchers obtained data on 18,886 carotid arteries stented between 2005 and 2020:

• TCAL procedures (n=809)—total endovascular treatment (simultaneously) of a common carotid artery lesion and an internal carotid artery or bifurcation lesion
• ICAL procedures (n=18,077)—endovascular treatment of an isolated internal carotid artery or bifurcation lesion

11,116 lesions (59%) were symptomatic. The primary outcome was the composite of perioperative stroke or death. Postoperative cardiac events were the composite of myocardial infarction, new dysrhythmia and exacerbation of congestive heart failure (CHF).

Perioperative Outcomes

Asymptomatic patients

• Stroke/death: 3.4% of those with TCAL vs. 1.8% of those with ICAL (P=0.03)
• 30-day mortality: 0.8% vs. 0.7% (P=0.83)
• Stroke: 2.9% vs. 1.2% (P=0.005)
• Postoperative cardiac events: 6.0% vs. 2.7% (P<0.001)

Symptomatic patients

• Stroke/death: 4.5% vs. 3.7% (P=0.41)
• 30-day mortality: 1.4% vs. 1.5% (P=0.86)
• Stroke: 3.3% vs. 2.5% (P=0.29)
• Postoperative cardiac events: 4.0% vs. 2.9% (P=0.18)

Multivariable Analysis

Asymptomatic patients

• Simultaneous treatment of TCAL was an independent risk factor for perioperative stroke/death (OR, 1.85; 95% CI, 1.03–3.33; P=0.04)
• Other significant risk factors were age, female sex, prior asymptomatic or symptomatic CHF, use of intraoperative contrast, use of general anesthesia and technical failure
• Protective factors were the use of a P2Y12 inhibitor within 36 hours before surgery (OR, 0.52) or preoperative statin therapy (OR, 0.64)

Symptomatic patients

• Simultaneous treatment of TCAL was not associated with stroke/death
• Significant risk factors were age, female sex, use of intraoperative contrast, functional dependence, prior symptomatic CHF, diabetes and end-stage renal disease on hemodialysis
• Protective factors were preoperative use of a P2Y12 inhibitor (OR, 0.74), neuroprotection success compared with failed or no neuroprotection (OR, 0.57) and increasing physician case volume (OR, 0.90 per quartile)

Recommendations for Vascular Surgeons

The total endovascular approach to TCAL should be considered for symptomatic patients. The hybrid approach might be a better option for asymptomatic patients who must undergo simultaneous treatment of TCAL, but this is unclear because neither the hybrid approach nor the total open approach has ever been directly compared with the total endovascular approach.

There are no data on the long-term natural history of leaving one or both tandem carotid artery lesions untreated. The available evidence suggests maximal medical therapy should be strongly considered in lieu of intervention for asymptomatic patients with quiescent-appearing lesions and those at higher procedural risk based on patient characteristics or anatomy.

Only 78% of this cohort received a P2Y12 inhibitor preoperatively, even though virtually every clinical practice guideline that addresses carotid artery stenting recommends dual-antiplatelet therapy, including a P2Y12 inhibitor, pre- and postoperatively. This gap in care should be targeted in quality improvement efforts to reduce rates of stroke/death.

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