Abstract 059: 2023 Highlights from the Prospective CASSH Registry
Authors: Ezzeldin M. , Delora A. , Martucci M. , Kahathuduwa C. N. , Hassan A. E. , Hussain M. S. , Miller S. , Chaubal V. , Ezzeldin R. , Mealer L. , Grandhi R. , Sheriff F. , Tanweer O. , Alaraj A. , Niazi M. , Bushnaq S. , Asif K. , Salah W. , Rodriguez G. , Maud A. , Shaikh S. , Navpreet B. , Bhatti I. , AlMajali M. , Abou-mrad T. , Nico E. , Quispe-Orozco D. , Abdulrazzak M. A. , Froukh M. , Zaidat O. , Siddiq F. 
Published: January 2025

Background
Multiple studies have highlighted the importance of carotid artery stenting (CAS) operator's experiences. However, fellowship‐trained neurointerventionalists (NIRs) remain an under‐represented specialty in the literature. The CASSH (Carotid Artery Stenting Outcomes in Comprehensive Stroke Hospitals) registry aims to provide comprehensive insights into CAS outcomes, particularly when performed by NIR at comprehensive stroke centers (CSCs).

Methods
CASSH is a multicenter, prospective, observational study regarding CAS performed by neurointerventional physicians for patients with carotid stenosis that was collected at multiple CSCs. The primary outcome included a composite of the 30‐day periprocedural mortality, symptomatic ischemic stroke, symptomatic intracranial hemorrhage (sICH), and myocardial infarction (MI). The secondary outcomes included other complications. All data were analyzed using R statistical software (Version 4.4.1). Categorical variables were summarized as proportions and continuous variables were summarized as medians and inter‐quartile ranges. Associations between categorical outcomes and other considered categorical variables were examined using Chi‐square tests of independence with Yates continuity correction. Associations between categorical variables of two categories and continuous variables were explored using Wilcoxon rank sum tests. Associations between categorical variables of more than two categories and continuous variables were examined using Kruskal Wallis tests and when appropriate, subsequent pair‐wise comparisons were performed using Wilcoxon rank sum tests using Holm Bonferroni corrections to adjust the threshold for statistical significance. Associations between continuous variables were examined using Spearman correlations.

Results
In 2023, 389 CAS procedures were performed in 12 CSCs across the United States. The primary outcomes occurred in 6 (1.5%) cases, with 1 (0.25%) 30‐day periprocedural mortality, 2 (0.5 %) symptomatic ischemic stroke, 2 (0.5%) sICH, and 1(0.25%) MI. The secondary outcome occurred in 18 patients (4.62%) with 6 (1.5) non‐periprocedural mortality, 9 (2.3%) access site complications, 1 (0.25%) TIA, 1 (0.25%) dissection secondary to CAS, and 1(0.25%) other complication. One patient had both a primary outcome of symptomatic ischemic stroke in addition to non‐periprocedural mortality. History of cerebrovascular accident (P=0.003), symptomatic carotid disease (P<0.011), and aortic arch type (P=0.038) were predictors of post‐procedure complications. Increased fluoroscopy time with a median= 21.7 minutes (interquartile range, 15.075 ‐ 34), and obesity (BMI= 27.14, interquartile range, 24.20 ‐ 31.70) were also associated with post‐procedure complications.

Conclusion
CAS, demonstrates favorable outcomes when performed by fellowship‐trained NIR physicians CSCs, with a complication rate of 1.5% of 30‐day periprocedural mortality, symptomatic ischemic stroke, symptomatic intracranial hemorrhage (sICH), and MI. This underscores the effectiveness and safety of CAS in this specialized setting.