Perioperative and Long-term Outcomes After Carotid Endarterectomy in Hemodialysis Patients | Acute Coronary Syndromes | JAMA Surgery | JAMA Network
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Original Investigation
October 2016

Perioperative and Long-term Outcomes After Carotid Endarterectomy in Hemodialysis Patients

Author Affiliations
  • 1Johns Hopkins Medical Institutions, Baltimore, Maryland
JAMA Surg. 2016;151(10):947-952. doi:10.1001/jamasurg.2016.1504
Key Points

Question  Is carotid endarterectomy (CEA) safe and effective in dialysis-dependent patients?

Findings  In this review of 5142 dialysis-dependent patients who underwent CEA, complications were high. The 30-day stroke rate, myocardial infarction, and mortality for the asymptomatic and symptomatic groups were 2.7% vs 5.2%, 4.6% vs 5.0%, and 2.6% vs 2.9%, respectively; 5-year stroke-free and overall survival were low in both the symptomatic and asymptomatic cohorts.

Meaning  The risks outweigh the benefits of CEA in asymptomatic patients and CEA should only be offered for a carefully selected cohort of symptomatic patients.

Abstract

Importance  Early landmark trials excluding dialysis patients showed carotid endarterectomy (CEA) decreased stroke risk compared with medical management. Dialysis dependence has been associated with poor outcomes after CEA in small studies, but, to our knowledge, there are no large studies evaluating outcomes of CEA in this patient group.

Objective  To delineate perioperative and long-term outcomes after CEA in dialysis-dependent patients in a large national database.

Design, Setting, and Participants  A retrospective review of all patients who underwent CEA in the US Renal Disease System–Medicare-matched database between January 1, 2006, and December 31, 2011, was performed in June 2015. The median follow-up time was 2.5 years. Logistic and Cox regression analyses were used to evaluate perioperative and long-term outcomes.

Main Outcomes and Measures  The primary outcomes of interest were perioperative stroke, myocardial infarction and mortality, and long-term stroke and mortality.

Results  A total of 5142 patients were studied; 83% of whom were asymptomatic. The mean (SD) age was 68.9 (9.6) years for asymptomatic patients and 70.0 (9.1) years for symptomatic patients. The 30-day stroke rate, myocardial infarction, and mortality for the asymptomatic and symptomatic groups were 2.7% vs 5.2% (P = .001), 4.6% vs 5.0% (P = .69), and 2.6% vs 2.9% (P = .61), respectively. Predictors of perioperative stroke were symptomatic status (odds ratio [OR], 2.01; 95% CI, 1.18-3.42; P = .01), black race (OR, 2.30; 95% CI, 1.24-4.25; P = .008), and Hispanic ethnicity (OR, 2.28; 95% CI, 1.17-4.42; P = .02). Freedom from stroke and overall survival were lower in symptomatic compared with asymptomatic patients at 1, 2, 3, 4, and 5 years (in asymptomatic vs symptomatic patients, freedom from stroke rates were 92% vs 87% at 1 year, 88% vs 83% at 2 years, 84% vs 78% at 3 years, 80% vs 73% at 4 years, and 79% vs 69% at 5 years, respectively, and overall survival rates were 78% vs 73% at 1 year, 60% vs 57% at 2 years, 46% vs 42% at 3 years, 37% vs 32% at 4 years, and 33% vs 29% at 5 years; P < .05). Predictors of long-term stroke were preoperative symptoms (hazard ratio, 1.67; 95% CI, 1.24-2.24; P < .001), female sex (hazard ratio, 1.34; 95% CI, 1.03-1.73; P = .04), and inability to ambulate (hazard ratio, 1.81; 95% CI, 1.25-2.62; P = .002). Predictors of long-term mortality were increasing age (OR, 1.02; 95% CI, 1.01-1.03; P < .01), active smoking (OR, 1.22; 95% CI, 1.00-1.48; P = .045), history of congestive heart failure (OR, 1.25; 95% CI, 1.12-1.39; P < .001), and chronic obstructive pulmonary disease (OR, 1.26; 95% CI, 1.09-1.45; P = .002).

Conclusions and Relevance  To our knowledge, this is the largest study to date of dialysis patients who have undergone CEA. We have shown that the risks of CEA in asymptomatic patients is high and may outweigh the benefits. The risk of CEA in symptomatic patients is also high, and it should only be offered to a small carefully selected cohort of symptomatic patients.

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