Impact of Access Site on Carotid Artery Stenting in Patients with Challenging Aortic Arch Anatomy.

Abstract

Background: Aortic arch anatomy can pose challenges during carotid artery stenting (CAS). Transradial carotid artery stenting (TRCAS) offers an alternative to transfemoral carotid artery stenting (TFCAS). This study reports on the impact of access site on CAS outcomes across different aortic arch anatomies.

Methods: The Vascular Quality Initiative (VQI) database was queried for patients who underwent TRCAS or TFCAS between 2017-2024. Exclusion criteria included patients with transcarotid artery revascularizations, intracranial revascularizations, dissections, aneurysms, trauma, and fibromuscular dysplasia. Patients were categorized by aortic arch type (type I, II, or III) and presence of a bovine arch. Symptomatic and asymptomatic patients were separately analyzed. Primary outcomes included postoperative stroke, transient ischemic attack (TIA), myocardial infarction (MI), in-hospital mortality, and access site complications. Secondary outcomes included procedure time, fluoroscopy time, contrast volume, and length of hospital stay.

Results: 14,351 patients (5.78% TRCAS; 94.21% TFCAS) were included in the analysis. TRCAS was used more frequently in bovine (18.92% of TRCAS; 11.33% of TFCAS), type II (43.98% of TRCAS; 35.90% of TFCAS), and type III (19.28% of TRCAS; 11.70% of TFCAS) arches, as well as symptomatic (70.84% of TRCAS; 58.42% of TFCAS) and right sided (59.40% of TRCAS; 49.62% of TFCAS) lesions (p<0.001). TRCAS showed no significant difference in primary outcomes after multivariate analysis except in symptomatic patients with right sided carotid lesions, where a type III arch increased the risk of postoperative stroke/TIA by over threefold (aOR: 3.52; 95% CI: 1.42 - 8.75; p = 0.007). In bovine arches, TRCAS did not impact primary outcomes. Access site complications were similar between the two cohorts and occurred in fewer than 4%. For secondary outcomes, multivariate analysis showed no difference between TRCAS and TFCAS, except for increased fluoroscopy time in patients with type I arches undergoing TRCAS (coefficient: 6.20 mins, 95% CI: 2.91 - 9.49). When stratified by lesion laterality and symptom status, asymptomatic patients with right-sided lesions and type II arches had shorter procedure times with TRCAS (coefficient: -7.16 mins, 95% CI: -13.66 - -0.66, p = 0.031) and required less contrast (coefficient: -11.39 mL, 95% CI: -22.38 - -0.41, p=0.042).

Conclusions: TRCAS and TFCAS offer similar risk of postoperative stroke/TIA, and access site complications in patients with type I, II, and bovine arch, regardless of lesion laterality or symptom status. However, in symptomatic patients with right sided lesions and type III aortic arch, TRCAS is associated with higher risk of postoperative cerebrovascular events, contrary to previous suggestions of safety benefits.