Perioperative Stroke in Carotid Artery Stenting as a Surrogate Marker and Predictor for 30-day Postprocedural Mortality - A Pooled Analysis of 156,000 Patients with Carotid Artery Disease

Background: Carotid artery stenosis (CAS) is being recognized as an effective alternative for carotid endarterectomy (CEA). CAS is especially preferred over CEA in high-risk surgical patients with severe carotid stenosis. However, CAS carries an increased risk of stroke and transient ischemic attack (TIA). Objective: To assess the association between periprocedural stroke/TIA and 30-day mortality in carotid stenosis patients undergoing CAS. Methods: We searched PubMed, Embase, and World Science for relevant publications. Studies reporting on perioperative neurologic status (stroke/TIA) and 30-day mortality in patients undergoing CAS were included. Sensitivity, specificity, pooled odds ratio (OR), and relative risk (RR) of perioperative stroke in predicting 30-day mortality following CAS were calculated. Results: 146 studies with 156,854 patients were included in the meta-analysis. The mean patient age was 70.7 years, and 57.6% were males. Only 26.5% of the CAS cohort were symptomatic and 15.2% had bilateral carotid disease. The incidence of perioperative TIA and stroke were 2.4 and 2.7 per 100 CAS procedure, respectively. Around 11.8% of stroke-events were fatal. The pooled OR of 30-day mortality after perioperative stroke was 24.58 (95% CI, 19.92-30.32) and the pooled RR was 21.65 (95% CI, 17.87-26.22). Perioperative stroke had a sensitivity of 42.0% (95% CI 37.8-46.4%) and specificity of 97.0% (95% CI 96.7-97.3%) in predicting 30-day mortality. Conclusions: Perioperative stroke drastically increases the risk of 30-day mortality. The occurrence of perioperative stroke exhibited high specificity but modest sensitivity in predicting 30-day mortality following CAS. This highlights the importance of neurophysiologic monitoring to detect intraoperative cerebral ischemia and perform timely interventions.