Retrospective Analysis of a Novel Grading System for Evaluating the Long-Term Benefit of Revascularization on Carotid Artery Stenosis.

BACKGROUND

To estimate revascularization benefit for carotid artery stenosis, with a novel grading system containing symptoms, stenosis, plaque, and collateral compensation (SSPC grading system).

METHODS

A retrospective multicenter study examined 945 consecutive patients diagnosed with carotid stenosis from January 2013 to December 2017. The cohort was classified into 2 groups: the revascularization group and the best medical therapy (BMT) group. Demographic, clinical, and lesion characteristics of all patients were recorded and 5-year nonprocedural stroke survival was calculated using Kaplan-Meier curve analyses.

RESULTS

Of the 945 patients, 514 underwent carotid revascularization (483 for carotid endarterectomy and 31 for transfemoral-carotid artery stenting) and 431 patients were treated with BMT. Patients in the revascularization group had a significantly higher proportion of preprocedural stroke/transient ischemic attack (TIA) and grades of stenosis. Of the patients in the revascularization group, 3.1% were classified as SSPC I, 10.3% as SSPC II, 41.4% as SSPC III, and 45.1% as SSPC IV. Meanwhile, 17.9% were classified as SSPC I, 19.7% as SSPC II, 49.2% as class III, and 13.2% had class IV in the BMT group. Procedural stroke developed in 13 patients (2.5%) following revascularization (10 of them were non-disabling). The overall rate of freedom from any nonprocedural stroke was 94.1 ± 1.1% in the revascularization group and 89.5 ± 1.6% in the BMT group (P = 0.01). Subgroup analysis was conducted for asymptomatic carotid stenosis (ACS) and carotid near-occlusion (CNO) patients. Nonsignificance was noted in the rate of freedom from any nonprocedural stroke between revascularization and BMT in both ACS and CNO subgroups (P = 0.09 and 0.12, respectively). Of note, in ACS patients graded as SSPC III, a significant difference in stroke survival was found between the revascularization and BMT group (96.0 ± 2.0% vs. 89.1 ± 2.4%, P = 0.04). Meanwhile, in symptomatic CNO patients, similar results were found regarding SSPC classification (94.8 ± 3.6% vs. 63.8 ± 14.9%, P = 0.01).

CONCLUSIONS

The SSPC grading system stratifies the patients with carotid artery stenosis and predicts the long-term benefits of revascularization. Meanwhile, potential revascularization benefits could be better attained via SSPC classes in specific patients with ACS and CNO.