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Carotid Duplex Poorly Predicts Stroke Risk During Transcatheter Aortic Valve Replacement

Published:January 04, 2022DOI:https://doi.org/10.1016/j.avsg.2021.12.075

      Introduction

      Patients undergoing surgical aortic valve replacement, in isolation or with concomitant coronary artery bypass grafting, have historically been screened for carotid artery disease prior to surgery. Over the past decade, transcatheter aortic valve replacement (TAVR) has incrementally become the predominant technique for the treatment of severe aortic stenosis. The relationship between internal carotid artery stenosis (ICAS) and risk of periprocedural stroke in the TAVR population is uncertain. We sought to evaluate our institution's outcomes with the TAVR procedure and the association with preoperative carotid duplex scan (CDS) results.

      Methods

      A retrospective review of a single institution TAVR registry over a 5-year period was performed. All patients with pre-operative carotid imaging were included. Outcomes included in-hospital, 30-day, and 1-year stroke and all-cause mortality rates. The diagnosis of post-operative stroke was based on neurological exam and confirmed by radiologic imaging. Standard statistical analysis was performed.

      Results

      A total of 436 patients met inclusion criteria. The prevalence of ICAS >50% was 18.3% and 70-99% stenosis was 4.8%. The in-hospital stroke and mortality rates were 2.3% and 1.2%, respectively. The cumulative 30-day and 1- year stroke rates were 3.7% and 6%, respectively. All were ischemic in nature. Bilateral infarcts were identified in 46.2% of stroke patients and 11.5% had an ipsilateral ICAS >50%. A large majority of stroke patients (23, 88.5%) had an ipsilateral ICAS of <50%. Less than 0.5% of patients had ICAS >70% and subsequently had an ipsilateral stroke within 30 days of procedure.

      Conclusions

      The preoperative CDS identified carotid lesions that met criteria for elective repair in only 4.8% of patients. Of these, 9.5% suffered a stroke in the first 30 days after surgery. Over 90% of patients who had a stroke had less than 70% stenosis present in either carotid artery and there was no correlation between degree of ICAS and risk of stroke during the follow-up period. Routine CDS prior to TAVR does not predict in-hospital or 30-day stroke. As TAVR programs evolve, expand, and proliferate across the country, routine preoperative CDS is unlikely to determine the need for pre-operative carotid revascularization or predict stroke risk.
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      REFERENCES

        • Kochanek KD
        • Xu J
        • Arias E.
        Mortality in the United States.
        NCHS Data Brief. 2019; (2020): 1-8
        • Schwartz LB
        • Bridgman AH
        • Kieffer RW
        • et al.
        Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass.
        J Vasc Surg. 1995; 21: 146-153
        • Gilman S.
        Cerebral disorders after open-heart operations.
        N Engl J Med. 1965; 272: 489-498
        • Ricotta JJ
        • Aburahma A
        • Ascher E
        • et al.
        Updated society for vascular surgery guidelines for management of extracranial carotid disease.
        J Vasc Surg. 2011; 54: e1-31
        • Sheng SP
        • Strassle PD
        • Arora S
        • et al.
        In-hospital outcomes after transcatheter versus surgical aortic valve replacement in octogenarians.
        J Am Heart Assoc. 2019; 8e011206
        • Huded CP
        • Tuzcu EM
        • Krishnaswamy A
        • et al.
        Association between transcatheter aortic valve replacement and early postprocedural stroke.
        JAMA. 2019; 321: 2306-2315
        • Kochar A
        • Li Z
        • Harrison JK
        • et al.
        Stroke and cardiovascular outcomes in patients with carotid disease undergoing transcatheter aortic valve replacement.
        Circ Cardiovasc Interv. 2018; 11e006322
        • Omran H
        • Schmidt H
        • Hackenbroch M
        • et al.
        Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: a prospective, randomised study.
        Lancet. 2003; 361: 1241-1246
        • Kapadia SR
        • Kodali S
        • Makkar R
        • et al.
        Protection against cerebral embolism during transcatheter aortic valve replacement.
        J Am Coll Cardiol. 2017; 69: 367-377
        • Faroux L
        • Junquera L
        • Mohammadi S
        • et al.
        Femoral versus nonfemoral subclavian/carotid arterial access route for transcatheter aortic valve replacement: a systematic review and meta-analysis.
        J Am Heart Assoc. 2020; 9e017460
        • Pour-Ghaz I
        • Raja J
        • Bayoumi M
        • et al.
        Transcatheter aortic valve replacement with a focus on transcarotid: a review of the current literature.
        Ann Transl Med. 2019; 7: 420
        • AbuRahma AF
        • Avgerinos EM
        • Chang RW
        • et al.
        Society for vascular surgery clinical practice guidelines for management of extracranial cerebrovascular disease.
        J Vasc Surg. 2021; 75: 4S-22S
        • Naylor AR
        • Ricco JB
        • de Borst GJ
        • et al.
        Editor's choice - management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the european society for vascular surgery (ESVS).
        Eur J Vasc Endovasc Surg. 2018; 55: 3-81
        • Thourani VH
        • O'Brien SM
        • Kelly JJ
        • et al.
        Development and application of a risk prediction model for in-hospital stroke after transcatheter aortic valve replacement: a report from the society of thoracic surgeons/american college of cardiology transcatheter valve therapy registry.
        Ann Thorac Surg. 2019; 107: 1097-1103