Young patients undergoing carotid stenting procedures have an increased rate of procedural failure at 1-year follow-up

Objective: The outcomes of patients with premature cerebrovascular disease (age <= 55 years) who undergo carotid artery stenting are not well-defined. Our study objective was to analyze the outcomes of younger patients undergoing carotid stenting. Methods: The Society for Vascular Surgery Vascular Quality Initiative was queried for transfemoral carotid artery stenting (TF-CAS) and transcarotid artery revascularization (TCAR) procedures between 2016 and 2020. Patients were stratified based on age <= 55 or >55 years. Primary endpoints were periprocedural stroke, death, myocardial infarction (MI), and composite outcomes. Secondary endpoints included procedural failure (defined as ipsilateral restenosis >= 80% or occlusion) and reintervention rates. Results: Of the 35,802 patients who underwent either TF-CAS or TCAR, 2912 (6.1%) were <= 55 years. Younger patients were less likely than older patients to have coronary disease (30.5% vs 50.2%; P <.001), diabetes (31.5% vs 37.9%; P <.001), and hypertension (71.8% vs 89.8%; P <.001), but were more likely to be female (45% vs 35.4%; P <.001) and active smokers (50.9% vs 24.0%; P <.001) Younger patients were also more likely to have had a prior transient ischemic attack or stroke than older patients (70.7% vs 56.9%; P <.001). TF-CAS was more frequently performed in younger patients (79.7% vs 55.4%; P <.001). In the periprocedural period, younger patients were less likely to have a MI than older patients (0.3% vs 0.7%; P <.001), but there was no significant difference in the rates of periprocedural stroke (1.5% vs 2.0%; P =.173) and composite outcomes of stroke/death (2.6% vs 2.7%; P =.686) and stroke/death/MI (2.9% vs 3.2%; P =.353) between our two cohorts. The mean follow-up was 12 months regardless of age. During follow-up, younger patients were significantly more likely to experience significant ($80%) restenosis or occlusion (4.7% vs 2.3%; P =.001) and to undergo reintervention (3.3% vs 1.7%; P <.001). However, there was no statistical difference in the frequency of late strokes between younger and older patients (3.8% vs 3.2%; P = .129). Conclusions: Patients with premature cerebrovascular disease undergoing carotid artery stenting are more likely to be African American, female, and active smokers than their older counterparts. Young patients are also more likely to present symptomatically. Although periprocedural outcomes are similar, younger patients have higher rates of procedural failure (significant restenosis or occlusion) and reintervention at 1-year follow-up. However, the clinical implication of late procedural failure is unknown, given that we found no significant difference in the rate of stroke at follow-up. Until further longitudinal studies are completed, clinicians should carefully consider the indications for carotid stenting in patients with premature cerebrovascular disease, and those who do undergo stenting may require close follow-up.