CTA-defined calcified nodules as a predictor of adverse outcomes following carotid revascularization

Abstract Carotid calcification can complicate carotid artery stenting (CAS), but its clinical impact may depend on calcification morphology rather than calcification burden alone. We retrospectively evaluated 92 patients who underwent carotid revascularization with either carotid endarterectomy (CEA) or CAS and classified preoperative computed tomography angiography (CTA) findings as no/spotty calcification (Group 1), outer calcification (Group 2), or bulky calcification directly abutting the contrast-enhanced lumen (Group 3). The primary composite endpoint comprised procedural failure, ischemic complications, or restenosis. The endpoint occurred in four of 83 patients (4.8%) in Groups 1/2 and five of nine patients (55.6%) in Group 3 (unadjusted odds ratio [OR], 24.69; 95% confidence interval [CI], 4.72–129.14; p < 0.001). In a parsimonious multivariable model including treatment modality and calcification pattern, Group 3 remained associated with the composite endpoint (adjusted OR, 49.05; 95% CI, 4.82–498.94; p = 0.001), whereas CEA was associated with lower odds of reaching the endpoint (adjusted OR, 0.045; 95% CI, 0.003–0.664; p = 0.024). Among patients who underwent CAS, the endpoint occurred in three of 38 patients (7.9%) in Groups 1/2 and all five patients (100%) in Group 3 (p < 0.001). CTA-defined bulky calcification may identify lesions at particularly high risk for CAS-related technical failure or restenosis and may support consideration of CEA when surgically feasible.