CCO Predicts In-Hospital Events in Patients With Stenosis Undergoing CEA but Not CAS

In patients with carotid artery stenosis who underwent revascularization procedures, the presence of contralateral carotid occlusion (CCO) was associated with significantly elevated risk of in-hospital adverse outcomes in patients treated with carotid endarterectomy (CEA) but not those who were revascularized via coronary artery stenting (CAS), according to a study published in the Journal of the American College of Cardiology.

Although CCO has traditionally been considered a high-risk feature for potential CEA candidates – and a rationale for shifting to CAS – recent research has given clinicians reason to question whether the presence of CCO should still be considered high risk in the context of CEA. Investigators sought to determine the real-world impact of CCO on patients who underwent CEA or CAS between 2007 and 2019, using contemporary data from national registries.

In this study, individuals who underwent CEA or CAS were enrolled using data from the American College of Cardiology’s National Cardiovascular Data Registry Carotid Artery Revascularization and Endarterectomy (NCDR CARE) and Peripheral Vascular Intervention (PVI) patient registries. Presence of CCO (100% internal carotid artery occlusion contralateral to the interventional site) was the primary exposure, whereas the primary endpoint was a composite of in-hospital adverse events (death, myocardial infarction, or stroke).

Secondary endpoints included the composite score’s components and transient ischemic attack (TIA). Multivariable-adjusted logistic regression was performed to calculate odds ratios (ORs) in order to compare the clinical impact of CCO in CEA vs CAS recipients.

There was a total of 58,423 patients who underwent carotid revascularization, with CCO identified in 4624 (7.9%; mean age, 69.5±9.7 years; 32.6% women; 92.8% White). Among those with a CCO, 1439 (31.1%) underwent CEA and 3185 (68.9%) were treated with CAS.

At baseline, 51.7% and 45.4% of participants with a CCO had a history of previous stroke/TIA and demonstrated disease symptoms, respectively. Among those with a CCO, the CAS group had more comorbidities and greater procedural risk than the CEA group.

Throughout the duration of the study, CCO prevalence decreased by 41.7% (10.3% to 6.0%) among those who underwent revascularization (P <.001). However, during this time, the primary carotid revascularization strategy remained CAS.

In unadjusted analyses, the composite outcome occurred more often in patients with CCO who were treated with CEA (3.6%) compared to those who underwent CAS (2.1%; P <.01). After adjustment, the presence of CCO in revascularization patients was significantly associated with a 71% uptick in the chances of experiencing a postprocedural adverse event among those who underwent CEA (OR 1.71; 95% CI, 1.27-2.30; P <.01), but there was no increase in those treated with CAS (OR 0.94; 95% CI, 0.72-1.22; P =.64). Stratification by presence or absence of symptoms did not alter the findings in either case.

Study limitations included a lack of randomization of participants, potential unmeasured confounders, lack of direct comparison of CCO patients in the 2 groups, use of voluntary registries that could introduce selection bias, possible nongeneralizability to populations with different demographics, lack of information regarding intermediate- and long-term outcomes, and the possibility that these registries may not include data from high-volume vascular surgeons.

“These data support the continued use of CCO to guide the selection of carotid revascularization strategies among patients with carotid artery disease,” noted the study authors. “An area for future investigation is whether outcomes may improve if high-volume centers were created that focused on patients with CCO.”


Krawisz AK, Rosenfield K, White CJ, et al. Clinical impact of contralateral carotid occlusion in patients undergoing carotid artery revascularization. J Am Coll Cardiol. 2021;77(7):835-844. doi:10.1016/j.jacc.2020.12.032