Carotid Artery Stenting in the Presence of Bovine Aortic Arch: A Multicentre Analysis of Procedure Outcomes and Access Modalities.

Abstract

While bovine aortic arch (BAA) is the most common aortic arch variant and has been associated with an increased risk of stroke in the general population, limited data exist on the impact of BAA on outcomes following carotid artery stenting (CAS). This study evaluated the association between BAA and post-operative outcomes in patients undergoing CAS. A retrospective analysis of the multi-institutional Vascular Quality Initiative database identified all patients undergoing CAS for atherosclerotic carotid stenosis from January 2017 to February 2024. Patients were stratified by the presence of BAA. Procedures included transcarotid artery revascularisation (TCAR) with flow reversal, transfemoral CAS (tfCAS), and transbrachial and transradial CAS (tb/trCAS) using distal embolic protection. The primary outcome was in hospital stroke or death. Secondary outcomes included stroke, death, myocardial infarction (MI), access related complications, and stroke and transient ischaemic attack (TIA). Baseline characteristics were compared, and multivariable logistic regression was performed to adjust for potential confounders. Among 18 254 patients undergoing CAS, 2 037 (11.1%) had BAA. Patients with BAA were more likely to present with symptomatic and left sided carotid stenosis. After adjustment, BAA was not associated with increased odds of post-operative stroke, death, MI, or composite adverse events. Within the BAA cohort, peri-operative outcomes were comparable across TCAR, tfCAS, and tb/trCAS, regardless of symptom status. Independent predictors of in hospital stroke or death included history of congestive heart failure and advanced age. Outcomes did not differ by lesion laterality in patients with BAA. In this large, contemporary, multicentre study, BAA was not independently associated with increased peri-operative risk following CAS. In current practice, where access selection is guided by pre-operative imaging and clinical judgement, CAS can be performed with comparable post-operative outcomes in selected patients with BAA.