Periprocedural outcomes of embolic protection device use in carotid artery stenting.

Abstract

Carotid artery stenting (CAS) is frequently used in the management of carotid artery stenosis. Although the use of embolic protection devices (EPDs) is common, the association with lower mortality has been questioned. We aimed to assess the association between CAS with and without EPD and periprocedural stroke and mortality. We included patients from the nationwide Vascular Quality Initiative registry who underwent CAS between 2015 and 2019. Patients undergoing transcarotid artery revascularization were excluded. Outcomes after CAS with either no EPD attempted or failed vs successful use of any EPD (distal or proximal) were analyzed in propensity score 1:1 matching cohort. Logistic regression was used to assess in-hospital mortality and stroke and transient ischemic attack outcomes (odds ratio [OR] with 95% confidence interval [CI]). Kaplan-Meier and Cox-proportional hazards regression were used to derive 30-day mortality cumulative incidence and risk. Analyses were replicated using inverse propensity weighting as a sensitivity analysis. A total of 19,451 patients were included, with 2062 per EPD group after 1:1 p propensity score matching (aged 67.1 ± 11.7 years; 41.4% female; 87.1% White). CAS without EPD was significantly associated with higher odds of in-hospital mortality (OR, 2.40; 95% CI, 1.50-3.85; P < .001), but not stroke/transient ischemia attack (OR, 1.26; 95% CI, 0.91-1.75; P = .160). The 30-day cumulative incidence and risk of death were twice as high in patients without vs with EPD (OR, 4.3% [95% CI, 3.5%-5.3%] vs OR, 2.0% [95% CI, 1.4%-2.7%]; P < .001; and hazard ratio, 2.21 [95% CI, 1.51-3.24]; P < .001). Sensitivity analysis revealed similar results. Not using an EPD was associated with higher in-hospital and 30-day mortality outcome in CAS when compared with EPD used. As the use of CAS increases, our real-world evidence highlights the risks of not using an EPD and the potential for including this metric as part of national quality improvement efforts for adequate CAS practices.