Carotid endarterectomy and transcarotid artery revascularization can be performed with acceptable morbidity and mortality in patients with chronic kidney disease

Norma Elizaga; Rahul Ghosh; Nallely Saldana-Ruiz; Marc Schermerhorn; Peter Soden; Kirsten Dansey; Sara L Zettervall

doi:10.1016/j.jvs.2024.04.045

Carotid endarterectomy and transcarotid artery revascularization can be performed with acceptable morbidity and mortality in patients with chronic kidney disease

J Vasc Surg. 2024 Apr 20:S0741-5214(24)01068-1. doi: 10.1016/j.jvs.2024.04.045. Online ahead of print.

Authors

Norma Elizaga¹, Rahul Ghosh², Nallely Saldana-Ruiz³, Marc Schermerhorn⁴, Peter Soden⁵, Kirsten Dansey¹, Sara L Zettervall⁶

Affiliations

¹ Division of Vascular Surgery, University of Washington, Seattle, WA.
² Texas A&M University School of Medicine, College Station, TX.
³ Kaiser Permanente, San Diego, CA.
⁴ Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
⁵ Brown Surgical Associates, Providence, RI.
⁶ Division of Vascular Surgery, University of Washington, Seattle, WA. Electronic address: szetterv@uw.edu.

PMID: 38649102
DOI: 10.1016/j.jvs.2024.04.045

Abstract

Objective: Patients with chronic kidney disease (CKD) are considered a high-risk population, and the optimal approach to the treatment of carotid disease remains unclear. Thus, we compared outcomes following carotid revascularization for patients with CKD by operative approach of carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid arterial revascularization (TCAR).

Methods: The Vascular Quality Initiative was analyzed for patients undergoing carotid revascularizations (CEA, TFCAS, and TCAR) from 2016 to 2021. Patients with normal renal function (estimated glomular filtration rate >90 mL/min/1.72 m²) were excluded. Asymptomatic and symptomatic carotid stenosis were assessed separately. Preoperative demographics, operative details, and outcomes of 30-day mortality, stroke, myocardial infarction (MI), and composite variable of stroke/death were compared. Multivariable analysis adjusted for differences in groups, including CKD stage.

Results: A total of 90,343 patients with CKD underwent revascularization (CEA, n = 66,870; TCAR, n = 13,459; and TFCAS, n = 10,014; asymptomatic, 63%; symptomatic, 37%). Composite 30-day mortality/stroke rates were: asymptomatic: CEA, 1.4%; TCAR, 1.2%; TFCAS, 1.8%; and symptomatic: CEA, 2.7%; TCAR, 2.3%; TFCAS, 3.7%. In adjusted analysis, TCAR had lower 30-day mortality compared with CEA (asymptomatic: adjusted odds ratio [aOR], 0.4; 95% confidence interval [CI], 0.3-0.7; symptomatic: aOR, 0.5; 95% CI, 0.3-0.7), and no difference in stroke, MI, or the composite outcome of stroke/death in both symptom cohorts. TCAR had lower risk of other cardiac complications compared with CEA in asymptomatic patients (aOR, 0.7; 95% CI, 0.6-0.9) and had similar risk in symptomatic patients. Compared with TFCAS, TCAR patients had lower 30-day mortality (asymptomatic: aOR, 0.5; 95% CI, 0.2-0.95; symptomatic: aOR, 0.3; 95% CI, 0.2-0.4), stroke (symptomatic: aOR, 0.7; 95% CI, 0.5-0.97), and stroke/death (asymptomatic: aOR, 0.7; 95% CI, 0.5-0.97; symptomatic: aOR, 0.6; 95% CI, 0.4-0.7), but no differences in MI or other cardiac complications. Patients treated with TFCAS had higher 30-day mortality (aOR, 1.8; 95% CI, 1.2-2.5) and stroke risk (aOR, 1.3; 95% CI, 1.02-1.7) in symptomatic patients compared with CEA. There were no differences in MI or other cardiac complications.

Conclusions: Among patients with CKD, TCAR and CEA showed rates of stroke/death less than 2% for asymptomatic patients and less than 3% for symptomatic patients. Given the increased risk of major morbidity and mortality, TFCAS should not be performed in patients with CKD who are otherwise anatomic candidates for TCAR or CEA.

Keywords: Carotid disease; Carotid stenosis; Carotid stenting; Chronic kidney disease; End-stage renal disease; Transcarotid artery revascularization.