Carotid disease treatment modality and its association with post-operative vasoactive medication utilization and hospital length of stay.

Objective: Carotid artery disease is a major cause of stroke for which the standard treatment has traditionally been a combination of medical management and intervention, including both carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS). In recent years, transcarotid artery revascularization (TCAR) has been adopted as a promising treatment following FDA approval in 2015. In terms of stroke reduction, TCAR has been found to have equivalent outcomes with CEA with shorter operative times. A well-described side effect of TCAR is the stimulation of baroreceptors in the carotid bulb resulting in bradycardia and blood pressure variability that may require vasopressor support. This has the potential to lengthen both ICU and entire hospital stay. The goal of this retrospective cohort study was to determine whether there is a difference in post-operative vasopressor or vasodilator treatment between traditional CEA, TF-CAS or TCAR and whether it affects ICU and/or overall hospital lengths of stay.

Methods: The Kaiser Permanente Southern California regional database was queried from January 2018 to December 2023 for all patients who underwent CEA, TF-CAS or TCAR at any Southern California Permanente Hospital. Chi-Square and Kruskal-Wallis tests were used to analyze patient characteristics and compare medication use and ICU and post-intervention length of stay in each intervention modality.

Results: The regional database query yielded 3012 patients who had undergone CEA, TF-CAS or TCAR. The average post-operative inpatient length of stay for TCAR patients (2.8 days) was shorter than CEA (3.7 days) and TF-CAS (5.6 days) (p < 0.0001). TCAR patients were more likely to have intravenous vasoactive medication (21.0%) compared to CEA (6.2%) and TF-CAS (7.7%) (p < 0.0001). Also, TCAR patients were more likely to have oral midodrine prescribed at any point in their hospitalization (9.1%) compared to CEA (0.5%) and TF-CAS (2.0%) (p < 0.001).

Conclusions: TCAR patients were more likely to require IV vasoactive medication post-operatively compared to CEA and TF-CAS. This is likely secondary to baroreceptor stimulation by balloon angioplasty and stent deployment. Further investigation to analyze why this is not as frequently seen with TF-CAS would be beneficial. Despite this, TCAR had lower post-operative ICU and hospital lengths of stay. Combining these findings with already reported benefits makes TCAR an attractive option in the operative treatment of carotid artery stenosis.