Revascularization of asymptomatic carotid stenosis is not appropriate in patients on dialysis

Abstract

Objective: Outcomes of carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) for asymptomatic disease in patients on dialysis are not well characterized, with questionable stroke prevention and survival. This study reports outcomes of carotid revascularization in asymptomatic dialysis patients in the United States.

Methods: Using United States Renal Data System (USRDS) databases, we identified all dialysis patients who underwent CEA or CAS for asymptomatic disease from 2005 to 2008. CEA and CAS were identified by Current Procedural Terminology (American Medical Association, Chicago, Ill) codes, and symptom status and comorbidities by International Classification of Diseases-9th Revision, Clinical Modification codes. Primary outcomes were stroke, cardiac complications, and death at 30 days and at 1 and 3 years. Predictors of death were identified using multivariate regression models.

Results: Of 738,561 dialysis patients, 2131 asymptomatic patients underwent carotid revascularization (1805 CEA, 326 CAS). The mortality rate was 4.7% at 30 days (4.6% CEA, 4.9% CAS; P = .807). Kaplan-Meier estimates of survival were 75.1% at 1 year (75.9% CEA, 70.7% CAS) and 43.4% at 3 years (43.7% CEA, 41.6% CAS). The stroke rate was 6.5% at 30 days (6.4% CEA, 6.9% CAS; P = .774) and 13.6% at 1 year (13.3% CEA, 15.0% CAS; P = .490). Cardiac complications occurred in 22.0% of patients (3.3% myocardial infarction) at 30 days (22.2% CEA, 20.6% CAS; P = .525). The combined stroke or death rate was 10.2% at 30 days (10.1% CEA, 10.9% CAS; P = .490) and 33.5% at 1 year (32.2% CEA, 39.6% CAS; P = .025). Age >70 years at the time of surgery and increased time on dialysis were predictive of death, whereas a history of renal transplant was a protective factor.

Conclusions: Patients on dialysis have high perioperative and long-term stroke or death rates after CEA or CAS for asymptomatic stenosis, with a median survival that is less than recommended by current guidelines. As a result, carotid intervention in these patients appears to be inappropriate.