Introduction: There has been an increase in the number of hemodialysis (HD) patients seeking treatment for carotid artery stenosis in recent times. These patients suffer from a unique course of cardiac and vascular disease and are often considered high risk for surgery. In this study, we compare long-term outcomes after carotid endarterectomy (CEA) versus angioplasty and stenting (CAS) in a large contemporary cohort of HD patients.
Methods: We studied all HD patients who underwent CEA and CAS in the United States Renal Disease System (USRDS) database between January 2006 and December 2011. Patient data were linked to the Medicare database to capture long-term outcomes. Univariable, multivariable cox regression, and propensity score matched analyses were employed to compare perioperative (stroke, death, MI) and long-term (stroke and death) outcomes following CAS vs. CEA.
Results: There were 6183 (CEA: 5121; CAS: 1062) carotid revascularizations performed in this cohort with a mean age of 67 (S.D 10.1) years. The majority of patients were male (60%), white (76%) and asymptomatic (CEA: 83%; CAS: 83%). Mean follow-up was of 1.6±1.3 years. Thirty day stroke (3.2 vs 5.5%) and death (4.6 vs 5.5%) were significantly lower after CEA. However, 30-day MI was similar between groups (3.2 vs 3.5%). Propensity score matched analysis showed a significantly higher risk of perioperative stroke after CAS compared to CEA (Table 1). Symptomatic status was a significant predictor of perioperative stroke (OR: 1.92; 95%CI: 1.33-2.77; P<0.001). Stroke-free survival for CEA vs CAS was 92% vs 90% at 1 year, 87% vs 85% at 2 years, and 81% vs 76% at 4 years.
Conclusions: This is the first study to compare long-term outcomes after CEA and CAS in a large cohort of HD patients. CAS is associated with a significantly higher risk of perioperative stroke compared to CEA. Long term stroke free survival is similar between groups, and differences appear to be largely driven by perioperative stroke rates.